Undetermined Malignant Potential Research Articles

7735 A Rare Case of Paraganglioma in Pregnancy

Abstract Disclosure: H. Kreit: None. J. Patel: None. N.L. Shah: None. K.B. Guttenberg: None. Introduction: Paragangliomas are rare neuroendocrine tumors that consist of an abnormal growth of chromaffin cells. Exceptionally rare is a paraganglioma in pregnancy. Case Report: A 30-year-old woman presented at 21 weeks gestation with a syncopal episode while ambulatory at work. She reported dizziness, palpitations, sweating, and dyspnea prior to this episode. In the Emergency Department, she was found to have supraventricular tachycardia (SVT) with a heart rate (HR) of 170 beats per minute that resolved after vagal maneuvers. Initial evaluation, including thyroid function tests and echocardiogram, was unremarkable. Symptoms were thought to be due pregnancy, and she was discharged home. She continued to report intermittent palpitations, sweating, and dizziness that resolved spontaneously. Due to her tachycardia and persistent symptoms, biochemical evaluation for pheochromocytoma was obtained at 30 weeks gestation. This was notable for elevated 24 hour urine normetanephrine (4462 mcg, normal 40-412 mcg), normal 24 hour urine metanephrine (85 mcg, normal 25-222 mcg), elevated plasma normetanephrine (1334.7 pg/mL, normal < 148 pg/mL), and normal plasma metanephrine (42.8 pg/mL, normal < 57 pg/mL). MRI abdomen and pelvis without contrast was unremarkable. She was readmitted to the hospital and started on doxazosin. This was followed by initiation of metoprolol and a high sodium diet. C-section was planned for 37 weeks gestation. One day prior to her scheduled C-section, she presented to the hospital with contractions. She was diagnosed with hypertensive emergency complicated by pulmonary edema. Emergent C-section was performed. MRI abdomen and pelvis with contrast subsequently revealed bilateral enhancing retroperitoneal masses, measuring 4.4 cm on the right and 3.7 cm on the left. Retroperitoneal masses were resected 3 months after delivery without complication. Pathology showed a left-sided paraganglioma and a right-sided paraganglioma of undetermined malignant potential. Genetic testing was recommended. Conclusion: Paraganglioma in pregnancy is very rare. If left unrecognized and untreated, it carries increased risk of mortality to both the fetus and mother. A multidisciplinary approach with close monitoring is crucial for management. Presentation: 6/1/2024

The indeterminate categories of the Milan system for reporting salivary gland cytopathology (MRSGC): A minireview

The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC), first published in 2018, attempted to develop a standardized and objective system of reporting salivary gland fine needle aspiration smears. It was widely accepted by the cytopathologists who started using it in their day-to-day practice. With the publication of new literature, the Milan system was updated and the 2 edition was released in 2023. The 5 WHO classification of salivary neoplasms, ancillary tests, and imaging characteristics of various salivary neoplasms have also been highlighted in the new edition. The 3 indeterminate categories of the Milan system of reporting are the atypia of undetermined significance (AUS), salivary gland tumor of undetermined malignant potential (SUMP), and suspicious for malignancy (SM) that create major dilemmas for the reporting cytopathologists. The present minireview highlights the criteria of diagnosis and further workup of the various lesions in these categories.

The Milan System for Reporting Salivary Gland Cytopathology: the experience of a tertiary cancer center with emphasis on non-mucinous cysts and improving diagnostic results

The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) was introduced in 2018 to standardize cytology reporting and guide patient treatment. We aimed to evaluate the utility of this system applied to patients at our cancer center. We retrospectively reviewed cases of salivary gland fine-needle aspirations (FNAs) performed in our institution (2019-2022). All were performed by radiologists and immediately assessed for specimen adequacy. The cytologic findings were classified into the MSRSGC except for non-mucinous cystic contents (NMCC) where the lesion was radiologically consistent with a cyst and totally collapsed after FNA. Such lesions were categorized as non-neoplastic (NN) instead of non-diagnostic (ND). The cytologic findings were compared to corresponding histologic findings (212 available cases), and the risk of malignancy was calculated. Five hundred five FNAs were categorized as: 25 (4.95%) ND; 86 (17.03%) NN, of which 39 were NMCC; 9 (1.78%) atypia of undetermined significance; 138 (27.33%) benign neoplasms; 57 (11.29%) salivary gland neoplasm of undetermined malignant potential; 16 (3.17%) suspicious for malignancy; and 174 (34.46%) malignant. The risk of malignancy rates for the following categories were: ND, 40%; NN, 25%; atypia of undetermined significance, 0%; benign neoplasms, 1%; salivary gland neoplasm of undetermined malignant potential, 54.54%; suspicious for malignancy, 90.9%; and malignant, 100%. Thirty-one NMCC with available follow-up resolved/remained stable. Our results validate the reproducibility of the MSRSGC applied in our cancer center. Based on the benign course of cysts with NMCC, we propose that such cases be categorized as NN, provided the cyst is totally resolved after FNA.

PD-L1 expression, morphology, and molecular characteristic of a subset of aggressive uterine tumor resembling ovarian sex cord tumor and a literature review

BackgroundUterine tumors resembling ovarian sex cord tumor (UTROSCT) is a rare neoplasm of unknown etiology and has undetermined malignant potential. The emergence of recurrent UTROSCT case reports has led to its initial identification as a tumor of low malignancy potential. Owing to its low incidence, we currently lack any in-depth studies regarding the subset of UTROSCTs that may be aggressive in nature. Here, we sought to identify unique characteristics in aggressive UTROSCT.Methods19 cases of UTROSCT were collected. Their histologic and tumor immune microenvironment were evaluated by three gynecologic pathologists. The gene alteration was also detected by RNA sequencing. For later analyses regarding differences between benign and malignant tumors, we supplemented our 19 included cases with additional reports from the literature.ResultsInterestingly, we found PD-L1 expression in stromal tumor-infiltrating immune cells (stromal PD-L1) was markedly higher in aggressive UTROSCT. Patients with high stromal PD-L1 (≥ 22.5 cells/mm2) had worse prognosis. When our cases were added with previous cases identified in the literature, we discovered that aggressive UTROSCT was more likely to have significant mitotic activity and NCOA2 gene alterations than benign UTROSCT. Consistence with those results, patients with significant mitotic activity and gene alteration of NCOA2 had worse prognoses.ConclusionsCollectively, high expression of stromal PD-L1, significant mitotic activity, and gene alteration of NCOA2 may be useful markers to predict aggressive UTROSCT.

Predictive assessment of micro RNA expression level and number of nucleolar organizer regions with follicular thyroid tumor of undetermined malignant potential

Introduction This article presents the current views on follicular thyroid tumor of undetermined malignant potential (FTUMP) taking into account the principles of WHO classification. Molecular genetic study with identification of mutation of some genes as well as determination of expression level of some microRNAs are given as methods for detection of potential predictors of oncodiagnostics. It was shown that the state of nucleus organizer regions is a marker of cell proliferation rate.The aim of the investigation was to estimate prognostic significance of expression level of some microRNAs and amount of regions of the nucleus organizers in the thyroid tissue at FTUMP to objectify approaches to development of adequate surgical tactics.Materials and methods Profile, microRNA expression level by real time PCR and regions of the nucleus organizers were studied in 98 cases of FTUMP which made up 4.75% of all cases of thyroid tumors operated on during four years.Results In 29 (29.6%) cases the spectrum of microRNA typical for malignant neoplasms was registered in the tissue of the FTUMP. In the remaining 69 (70.4%) cases out of 98 observations the spectrum and the expression level of microRNA corresponded to the follicular adenoma. Statistically significant differences in the average number of AgNORs and correlation between the cell area and the number of AgNORs granules were found within the formed subgroups.Discussion Increase of the mean number of AgNORs and the ratio of the nucleus area to the number of silver nitrate granules in the 2nd subgroup in comparison with the 1st one, as well as the appearance of the type II cells testifies to the appearance of the proliferating tumor cells in a new tumor growth and can be considered as prognostic criteria of tumor malignization. These results correlate with the findings of molecular-genetic study. Conclusion The data of the literature and the results obtained by studying the profile and the expression level of a number of microRNAs, morphometric characteristics and counting of thyrocyte nucleus organizer regions may serve as additional criteria for evaluation of the proliferative activity of the follicular epithelium in thyroid neoplasms, in particular to clarify the malignancy potential. Preoperatively diagnosed conditionally malignant FTUMP will allow to justify the necessity and amount of surgical intervention, and if a complex of criteria of conditionally benign FTUMP is revealed, to stick to the waiting tactics and refuse surgical intervention.

Outcome for Pediatric Adreno-Cortical Tumors Is Best Predicted by the COG Stage and Five-Item Microscopic Score-Report from the German MET Studies.

Background: Adrenocortical tumors (ACTs) encompassing the adrenocortical adenoma (ACA), carcinoma (ACC), and tumors of undetermined malignant potential (ACx) are rare endocrine neoplasms with a poor prognosis. We report on pediatric ACT patients registered with the Malignant Endocrine Tumor studies and explore the EXPeRT recommendations for management. Patients: Data from the ACT patients (<18 years) were analyzed. For the risk prediction, the patients were retrospectively assigned to the COG stages and the five-item score. Results: By December 2021, 161 patients with ACT (ACA n = 51, ACx n = 19, and ACC n = 91) had been reported (the median age at the diagnosis was 4.3 years with a range of 0.1−17.8), with lymph node and distant metastases in 10.7% and 18.9% of the patients with ACC/ACx. The mean follow-up was 4.5 years (with a range of 0−16.7). The three-year overall (OS) and event-free survival (EFS) rates were 65.5% and 50.6%. In the univariate analyses, the OS was impaired for patients aged ≥ 4 years (p = 0.001) with the initial biopsy (p = 0.016), tumor spillage (p = 0.028), incomplete tumor resection (p < 0.001), unfavorable histology (p = 0.047), and COG stages III/IV (p = 0.002). Multivariate analysis revealed COG stages III/IV and an unfavorable five-item score as independent negative prognostic factors for the EFS and OS. Conclusions: Age defines the clinical presentation and prognosis in pediatric ACTs. The outcome is best predicted by the COG stage and five-item score.

PSAT025 Functional Adrenocortical Oncocytic Neoplasm: A Rare Cause of ACTH Independent Cushing's Syndrome

Abstract Background Adrenal oncocytomas (AOCs) or adrenocortical oncocytic neoplasms (ACONs) are extremely rare tumors of adrenal glands characterized by the presence of oncocytes, which are epithelial cells with eosinophilic cytoplasm. Only about 140 cases have been reported in literature so far. AOCs are more common in females (2.5: 1), more prevalent on the left adrenal gland (3.5: 1), and tumor size ranges from 3 to 17 cm. About two thirds of AOCs are reported to be nonfunctioning, and only less than 6% of functioning are cortisol secreting. The malignant potential of these tumors has been described quite variably in current literature. Based on the most recent systematic literature review, about 35% were found to be benign, 24% malignant, and 41% borderline, based on the Lin Weiss Bisceglia system. The mainstay of treatment is surgical resection. Here we describe a case where biochemical workup and pathology revealed a functional AOC with uncertain malignant potential. Clinical Case A 68 year old female with hypertension was found to have an incidental left 3 cm adrenal nodule on CT abdomen and pelvis during a workup for hematuria. The nodule was biopsied and initially found to be benign. Afterwards, she was referred to endocrinology where biochemical testing was consistent with ACTH-independent Cushing's syndrome. She had three elevated late night salivary cortisol - 0.10 mcg/dL, 0.14 mcg/dL, and 0.19 mcg/dL (≤0. 09 mcg/dL), three abnormal 1 mg dexamethasone suppression tests - 16.4 mcg/dL, 15.1 mcg/dL, and 17.1 mcg/dL (&amp;lt;1.8 mcg/dL), two normal 24 hour urinary cortisol - 22.5 and 31.5 mcg/24h (4-50 mcg/24h), and ACTH &amp;lt;5 pg/mL (6-50 pg/mL). She was then referred to surgery and was treated by laparoscopic adrenalectomy. Surgical pathology showed a 3.5 cm adrenal cortical tumor with oncocytes infiltrating into the periadrenal adipose tissue, with positive staining for synaptophysin and negative for P53. On Ki67 staining, some hot spots were greater than 5%. Therefore, the tumor was characterized as AOC with undetermined malignant potential or a low grade, oncocytic adrenocortical carcinoma. She was evaluated by oncology and radiation oncology, and it was decided to monitor the patient without systemic therapy or adjuvant radiation therapy. A surveillance approach was favored given that the risks of adjacent bowel and kidney toxicity outweighed the benefits of radiation. Conclusion We hereby report a case of AOC with undetermined malignant potential. This case highlights many challenges in the diagnosis, management and long-term surveillance of patients with AOCs, and need for further research. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Diagnostic Accuracy and Analysis of Cytomorphological Images of Fine Needle Aspiration Biopsy in Salivary Gland Lesions Based on The Milan System for Reporting Salivary Gland Cytology (MSRSGC) Classification

BackgroundFine needle aspiration cytology (FNAC) is an effective, simple, and safe method of assessing salivary glandular lesions. The diagnosis of FNAC can be challenging for pathologists because of the heterogeneous morphological spectrum and overlapping of cytomorphologic salivary glands. The aim is to determine the diagnostic accuracy and analyze the cytomorphology of salivary glands aspiration based on The Milan System for Reporting Salivary Gland Cytology (MSRSGC).Methods A search for cytological preparations for salivary gland lesions in 2015-2019 was carried out in the archives of the Department of Anatomic Pathology, FKUI/RSCM. There were 215 cases of cytology of salivary gland lesions which re-evaluated and classified based on MSRSGC. There were 106 cases of cytologic-histopathologic paired data, 25 of which were excluded because the specimens were not filled the criteria for re-examination.ResultsThere were 81 cases of salivary gland lesions since 2015-2019 which were assessed and reclassified based on MSRSGC, consisting of 8 non-diagnostic, 1 non-neoplastic, 1 case of atypical of undetermined significance (AUS), 39 benign tumors, 10 salivary gland neoplasm of undetermined malignant potential (SUMP), 6 suspicious for malignancy (SFM) and 16 malignant tumors. Three of these cases had a different diagnosis result in false-negative on non-diagnostic and benign tumors. The sensitivity value was 91.17%, specificity 97.43%, positive predictive value (PPV) 96.87%, negative predictive value (NPV) 92.68% and 94.52% accuracy.ConclusionThe diagnosis of fine needle aspiration cytology can be accurately achieved by a combination of clinical information and radiologicalexamination, however a histopathologic examination is still required for definitive diganosis. MSRSGC classification is very helpful in the diagnosis of salivary gland cytology.

Histopathological Review of Diagnostic Categories of the Milan System for Reporting Salivary Gland Cytopathology - An Institutional Experience of 6 Years.

Introduction:Salivary gland malignancies account for 2 to 4% of head and neck cancers. Fine needle aspiration cytology (FNAC) is used in preoperative diagnosis of salivary gland lesions. Although FNAC is a highly reliable technique for preoperative diagnosis, there were no consensus on salivary gland cytopathology reporting. Recently, an international group has recommended a classification system for salivary gland FNAC reporting titled “Milan System for Reporting Salivary Gland Cytopathology” (MSRSGC). In this study, we aimed to evaluate the usability of the Milan System, its ability to determine the risk of malignancy for each category, with comparisons of inital cytologic and final histopathological diagnosis.Materials and Methods:We performed a retrospective analysis of salivary gland lesion FNAC in our department from 2013 to 2019. A total of 578 FNACs were performed in 514 patients. Of these, 85 cases had surgical follow-up (parotid gland, n = 73, submandibular gland, n = 12). The cytological samples were categorized according to the MSRSGC into six categories by two pathologists. The risk of malignancy (ROM) and diagnostic accuracy values were calculated for each diagnostic categories.Results:A total of 85 aspirates of the patients with follow-up, the MSRSGC diagnostic categories were as follows: non-diagnostic in 7 aspirates (8.2%), non-neoplastic in 3 (3.5%), atypia of undetermined significance (AUS) in 9 (10.5%), benign neoplasm in 43 (50.5%), salivary gland neoplasm of undetermined malignant potential in 7 (8.2%), suspicious for malignancy in 10 (11.7%), and malignant in 6 (7%). The ROM for each category was 28, 5%, 0%, 33%, 0%, 28.5%, 90%, and 100%, respectively.Conclusion:FNAC plays a critical role in the evaluation of patients with salivary gland lesions. The MSRSGC helps in the standardization of the process of diagnosis and clinical management of salivary gland lesions, especially of AUS and SUMP categories that are indeterminate categories in nature.

Massive Relief: Papillary Adenoma of the Lung in Asymptomatic Former Smoker Patient.

Benign epithelial tumors of the lung are uncommon and can represent a diagnostic challenge. Herein, we describe one such emblematic case. A 59-year-old former smoker male was admitted to the hospital complaining of cough for a long time. A radiological examination showed a centrally excavated mass strictly connected to the visceral pleura. The patient underwent tumorectomy. At gross examination, the tumor was composed of solid and cystic areas containing clear liquid. Histological examination highlighted a sub-pleural encapsulated tumor, with foci of capsular invasion, characterized by a single layer of columnar and cuboidal epithelial cells lining moderately cellular fibro-vascular cores. A wide spectrum of immunohistochemical markers was performed. The final diagnosis was suggestive of a peripheral pulmonary papillary tumor of undetermined malignant potential. At the last follow-up, six years after surgery, no recurrence or metastases were described. Reporting this case, we would like to point out the existence of these rare entities that should be taken into account in the diagnostic process, thus avoiding potential misdiagnosis. Moreover, the presence of capsular invasion should be better investigated in order to reconsider the exact terminology of the tumor and the classification of its malignant potential.

Histopathological study of thyroidectomy specimens

Diseases of thyroid gland are common and have wide spectrum of entities ranging from functional, immune mediated to neoplastic lesions. The aim of this study is to describe the different pattern of lesions in thyroidectomy specimens. To study occurrence of various lesions of thyroidectomy specimens.This study was done in Dept. of pathology, Mysore Medical College over a period of 2 years from Feb 2017 to Feb 2019. The thyroid diseases were classified on histological grounds into congenital, non- neoplastic and neoplastic lesions that were further sub classified as benign and malignant as per WHO histological classification of thyroid tumors. A total of 104 thyroidectomy specimens were received during this study period. 91 cases (87.5%) were females and 13 cases (12.5%) were males with F: M ratio of 7:1. Non neoplastic lesions accounted for 72% and includes colloid goiter, multinodular goiter, nodular hyperplasia, hashimoto’s thyroiditis, thyroglossal cyst and lymphocytic thyroiditis. Neoplastic lesions accounted for 30% and consists of follicular adenoma as benign neoplasm, 17 malignant cases, 13 cases were of papillary thyroid carcinoma classic type, two cases of follicular carcinoma, one case of well differentiated follicular carcinoma of undetermined malignant potential and one case of non invasive follicular tumor with papillary like nuclear features. Thyroid lesions predominantly affects females. Most commonly seen during 3decade of life. Colloid goiter is the commonest non-neoplastic followed by multinodular goiter. Follicular adenoma was the most common benign neoplasm, papillary carcinoma of thyroid was the common thyroid malignancy seen.

Application of Milan system for reporting of salivary gland pathology and risk stratification: An institutional experience

Background:Fine-needle aspiration cytology (FNAC) is a sensitive technique for diagnosing salivary gland pathologies. Milan system of reporting salivary gland cytopathology (MSRSGC) is an evidence-based system of reporting which has been introduced to improve reporting and communication between cytopathologist and clinician by introducing standardized categories with specified treatment protocols.Aims and Objectives:The aim of the present study is to find the diagnostic accuracy and risk of malignancy (ROM) in various categories when MSRSGC is applied.Materials and Methods:A single-institute-based 3-year retrospective study was done. All salivary gland lesions were reclassified according to MSRSGC. ROM, diagnostic specificity, sensitivity and accuracy of FNAC of salivary gland lesions were calculated.Results:A total of 133 cases were included in the study. Overall, the most common diagnosis was found to be pleomorphic adenoma comprising 61 (42.8%) of all cases. Adenoid cystic carcinoma was the most commonly diagnosed malignancy comprising of 6 (4.5%) of all lesions. Cases were further divided into Milan categories, namely nondiagnostic, nonneoplastic, atypia of undetermined significance, benign neoplasm, neoplasm of undetermined malignant potential, suspicious of malignancy and malignancy comprising 5 (3.7%), 29 (21.8%), 77 (57.8%), 4 (3%), 3 (2.2%), 1 (0.7%) and 14 (10.5%) cases, respectively, with ROM of 0, 14.28%, 33.33%, 5.71%, 66.66%, 100% and 80%, respectively. Sensitivity, specificity and diagnostic accuracy to separate benign from malignant lesions were 80%, 89.80% and 87.50%, respectively.Conclusion:FNAC of the salivary gland lesions is a safe and reliable diagnostic procedure. The Milan system of reporting is a risk stratification system which can improve the overall effectiveness of reporting and care of patients.

Giant hepatic angiomyolipoma: a case report.

Hepatic angiomyolipoma (AML) is a rare mesenchymal tumour with an undetermined malignant potential. Clinical symptoms are non-specific. The radiological hallmarks are high vascularization of lesion and presence of macroscopic fat. The proportion of fatty tissue varies significantly and discrepancies between pre-operative imaging and histological findings are observed in more than 50% of cases. Visualization of the draining vein may aid in differentiation between AML and hepatocellular carcinoma with abundant fatty component. Biopsy is indicated in ambiguous cases. Presence of clinical symptoms warrants surgical treatment. We present a clinical case of giant hepatic AML, discuss its typical features and treatment options.

Reporting of fine needle aspiration (FNA) specimens of salivary gland lesions: A comprehensive review.

Currently, there is no uniform classification scheme available for reporting of salivary gland fine-needle aspiration (FNA) specimens. Recently, an International group of pathologists has recommended a tiered classification scheme for reporting of salivary gland FNA results known as the "Milan System for Reporting Salivary Gland Cytopathology (MSRSGC)." We performed a comprehensive review of the published literature on FNA of salivary gland lesions by employing the diagnostic categories of the MSRSGC to evaluate their reliability in the management of salivary gland lesions. A comprehensive review of the literature was carried out through PubMed from 1987 to 2015 to identify studies which categorized the cytologic diagnoses and included surgical follow-up. Only cases with histopathologic follow-up were included in the analysis. Twenty-nine studies comprising 4514 cases of salivary gland FNAs with surgical follow-up were included in this study. The cytologic diagnoses were categorized into the following categories proposed by MSRSGC. The number of cases in each diagnostic category and the risk of malignancy (ROM) were as follows: Non-Diagnostic-100 cases (ROM- 25.0% ± 16.7%), Non-Neoplastic-587 cases (ROM: 10.2% ± 5.5%), Benign Neoplasm -2673 cases (ROM: 3.4% ± 1.3%), Salivary Gland Neoplasm of Undetermined Malignant Potential (SUMP)-64 cases(ROM: 37.5% ± 24.7%), Suspicious for Malignant neoplasm-70 cases(ROM: 58.6% ± 19.5%), and Malignant-1012 cases(ROM: 91.9% ± 3.5%). A tiered classification scheme as proposed by MSRSGC may prove helpful in effectively guiding clinical management of patients with salivary gland lesions.

CK19 IS A USEFUL MARKER IN DISTINGUISHING FOLLICULAR VARIANT OF PAPILLARY THYROID CARCINOMA FROM BENIGN THYROID LESIONS WITH FOLLICULAR GROWTH PATTERN.

Thyroid cancer is the most common endocrine malignancy. Within various subtypes of thyroid neoplasms, those with follicular growth pattern usually make diagnostic problems. To examine ck19 expression as a diagnostic marker in thyroid neoplasms with follicular growth pattern. In this cross sectional study, 86 patients were enrolled. Totally 22 follicular adenoma (FA), 18 well differentiated tumors with undetermined malignant potential (WT-UMP) and 46 follicular variants of papillary thyroid carcinoma (FV-PTC) were enrolled and examined for Ck19 expression by immunohistochemistry staining. Membranous/cytoplasmic staining patterns were considered as positive. Specimens without staining were considered as 0, < 5% positively stained cells as 1+, 5%-25% as 2+, 25%-75% as 3+ and >75% as 4+. CK19 was negative in most cases of FA while positive in most WDT-UMP and FV-PTCs, p<0.001. Additionally, most cases with 2+ and 3+ staining patterns were FV-PTC (75% and 81%, respectively, p<0.001) and none of FAs showed 3+ positivity (p<0.001). Additionally, most of strongly positive results in patients > 45 y/o were PTC (p<0.001). Ck19 is a useful marker in differentiating FA from FV-PTC. We found diffuse and strong (3+) staining pattern in FV-PTC but none of FAs were so. We concluded that diffuse and strong staining for ck19 in a thyroid lesion with follicular pattern of growth, especially in a patient older than 45 y/o should raise the possibility of malignancy.

A SOLITARY FIBROUS ORBITAL TUMOR IN A PATIENT WITH NEUROFIBROMATOSIS AND AN UTERINE CARCINOMA

We present a rare combination of a solitary fibrous orbital tumor and uterine cancer in a female patient with type I neurofibromatosis. This 77-year old patient developed a left painless exophthalmos within 2 years and decreased visual acuity of the left eye. At the age of 20 she was diagnosed with type I neurofibromatosis. Half a year ago she underwent hysteron-oophorectomy due to uterine adenocarcinoma. The visual acuity of her left eye was decreased to 0.3, with an increase of intraocular pressure to 30 mm Hg. She had a 13-mm left-sided exophthalmos with misplacement of the eye downwards and laterally at 40°. Reposition of the left eye was severely impaired, with limitation of the eye movements to all directions. Ophthalmoscopy showed optic disc discoloration and blunting of its inner border. The patient underwent trans-conjunctival orbitotomy, with removal of three encapsulated tumor nodules. Histological and immunochemical studies of the removed tissue identified solitary fibrous tumor of the left orbit with an undetermined malignant potential. In the post-operative period, visual acuity of the left eye was 0.2, with no exophthalmos and right position of the eye. There was a non-significant limitation of the left eye movement to the left and to the right. X-ray computed tomography confirmed radical tumor excision. Conclusion: Solitary fibrous tumor is a rare orbital neoplasm. Nevertheless, it should be included into the differential diagnosis list of spin-cell orbital tumors. It is necessary to aim at tumor removal through the least traumatic orbital access. Relapsing course of the tumor is the rationale for a long-term follow-up of patients after removal of solitary fibrous orbital tumor.

Smooth Muscle Tumor Originating in the Pleura: A Case Report and Updated Literature Review.

Smooth muscle tumors (SMTs) of the pleura are exceptionally rare. At present and to the best of these authors' knowledge, there are only 17 cases reported in the literature. We describe a case of a 51-year-old woman who complained of left sided pleuritic chest pain. Further, computed tomography (CT) revealed a left sided localized pleural-based mass involving the 9th rib. She underwent an interventional radiology guided percutaneous core biopsy of the lesion, which disclosed a “Smooth Muscle Tumor of Undetermined Malignant Potential (SMT-UMP).” A video-assisted thoracoscopic surgery (VATS) was performed for diagnosis and treatment purposes. Resections of the pleural-based mass and 9th rib were performed. SMT-UMP was the definitive diagnosis.

Robot-Assisted Excision of a Cervical Thymic Cyst Mimicking Possible Basal Cell Carcinoma Metastasis

Background: Basal Cell Carcinoma (BCC) is the most common skin malignancy in the head and neck area, cervical metastasis is not common but the risk still remains and cystic lesion had been reported. Cervical Thymic Cyst (CTC) is also a rare disorder. This report aims to describe a clinical puzzle of a CTC in an adult patient with history of facial BCC. We also introduce the new developed robot-assisted surgery for cervical excisional biopsy that is prerequisite for a definite pathologic diagnosis. Case reports: A 39-year-old woman with history of naso-labial fold BCC presented with a cervical cystic mass. To exclude the possibility of cervical metastasis, the robot assisted excisional biopsy was done via retro-auricular approach to avoid leaving a visible cervical scar. The lesion was proved to be a Cervical Thymic Cyst (CTC), which is rarely found in adults and she was satisfied with the invisible scar hidden in the hairline. Conclusion: For a neck mass with undetermined malignant potential, the robot-assisted excisional biopsy via retro-auricular approach is a good alternative with better cosmetic result.

Hepatic epithelioid hemangioendothelioma in a young female mimicking metastasis on radiology: Report of a case with brief review of literature

Hepatic epithelioid hemangioendothelioma, is a rare vascular tumor of undetermined malignant potential. Clinical symptoms and signs are nonspecific, and the diagnosis may be easily missed. We report a case of 23‑year‑old female who presented with right upper quadrant abdominal pain. Ultrasonography of the abdomen showed multiple discrete nodules in the liver with complex architecture and a hypo echoic centre. Contrast enhanced computed tomography was also performed, which showed peripheral rim enhancement in the arterial phase and “target‑sign” in portal and venous phases. These radiological findings suggested metastasis on radiology. However, serum alpha‑fetoprotein, CA‑125 and carcinoembryonic antigen were within the normal limits. A tru‑cut biopsy from the liver nodule showed the presence of tumor cells invading the liver, which was suggestive of epithelioid hemangioendothelioma and later confirmed by CD34 and CD31 immunostains. The patient, presently on thalidomide treatment regimen, is surviving with a stable disease.

Outcome of image-guided biopsies: Retrospective review of the West of Scotland musculoskeletal oncology service

IntroductionImage-guided needle biopsy of a suspected musculoskeletal malignancy has become increasingly popular as an effective modality for diagnosis. Our aim was to determine accuracy and success rates of the image guided biopsies performed by our service. MethodsA retrospective review of the Bone and Soft Tissue Sarcoma service database was performed to identify all patients who underwent image guided biopsy and to identify the results of such investigations. Patients who had an open biopsy or a biopsy performed at another institution were excluded from this review. A biopsy was deemed successful if a sample of the target lesion was sampled at the time of biopsy. The successful biopsies were then classified as diagnostic or non-diagnostic depending on whether the diagnosis was established from the sampled tissue. Results465 of the 1181 new referrals to the Bone and Soft Tissue Sarcoma service in a 4 year period underwent biopsy. 75% (350) were image guided biopsies – 60% (281) ultrasound and 15% (69) CT guided. The rate of successful ultrasound guided biopsy was 94.7% and the rate of a successful diagnostic biopsy was 93.6%. CT guided biopsies were successful in 95.7% and were both successful and diagnostic in 79.7%. DiscussionThe rate of a successful diagnostic ultrasound biopsy within our institution reflects the reported rate within the literature. The rate of a successful diagnostic CT guided biopsy is lower however is also consistent with that reported within the literature. Low grade lipomatous lesions and chondroid lesions of undetermined malignant potential (CLUMP) are associated with a more difficult histological diagnosis on biopsy alone which is consistent with our findings. For this reason our institution has stopped performing routine image guided biopsies on these lesions. Radiological low grade lipomatous lesions are treated with marginal excision and all CLUMP lesions undergo open biopsy.