Adenoid cystic carcinoma of the orbit: a single institute experience

Introduction/Objective

Adenoid cystic carcinoma (ADCC) is a malignant neoplasm usually arising from the major and minor salivary glands. Orbital ADCC arising from the lacrimal gland is rare. They present with morphology and immunohistochemical properties identical to their salivary gland counterparts. Due to their rarity, orbital ADCCs are poorly studied. Here, we describe our institutional experience of diagnosing ADCC in orbit.

Methods/Case Report

We queried the electronic laboratory information system for primary tumors arising in the orbit that resulted in the diagnosis of ADCC in the last twenty years. Clinical history, radiology, and immunohistochemical profile were obtained and summarized for all cases.

Results (if a Case Study enter NA)

Eight cases were with the diagnosis of orbital ADCC. The age at diagnosis ranged between 38 to 79 years, with most patients diagnosed between 41 to 50 years. The male to female ratio was 1:1. The tumor size varied between 1.5 to 8.7 cm. Most tumors were graded as grade III and showed perineural invasion. Five out of eight tumors showed predominantly solid architecture. The immunohistochemical pattern was similar to salivary gland ADCC, with one case showing MYB rearrangement.

Conclusion

Our data suggest that orbital ADCC closely resembles their salivary gland counterparts. Although small, our study broadens the general understanding of this rare group of malignancies.

Differentiation of intracranial Rosai‐Dorfman histiocytosis from meningioma using MR perfusion

Intracranial Rosai‐Dorfman disease may be indistinguishable from meningioma. This distinction is essential, as they are treated very differently. We present two cases where perfusion imaging helped make this distinction, allowing one to be treated successfully without craniotomy. Perfusion imaging may be a powerful adjunct in cases where RDD mimics meningioma.

Orbital cellulitis, sinusitis and intracranial abnormalities in two adolescents with COVID-19

We review two cases of adolescents with orbital cellulitis, sinusitis and SARS- CoV-2 infection presenting to emergency departments within a 24 hour period. SARS-CoV-2 samples obtained within 24 hours were positive, supporting prior infection despite relatively limited early symptoms of COVID-19. Unusual clinical and radiographic characteristics included hemorrhagic abscess with blood of varying age in the first, intracranial epidural abscess in the second, radiographic signal consistent with hemorrhagic or thrombotic phenomena, retro-maxillary antral fat changes, and meningeal enhancement or extension in both cases. Radiographic findings thereby mimic fungal infection, although final cultures and ancillary investigation for allergic and invasive fungal disease have remained negative. These cases highlight two unusual orbital presentations of cellulitis occurring in the context of SARS-CoV-2 co-infection.

Intravascular papillary endothelial hyperplasia of the periocular region

Intravascular papillary endothelial hyperplasia (IPEH) is a benign vascular lesion, typically found in the skin, consisting of a papillary proliferation of endothelial cells intimately related to a thrombus; it appears to be a rare variant of an organizing process. IPEH very rarely develops in the periocular region, with fewer than 20 such cases currently reported in the English language literature. We describe one of the largest ever case series of this uncommon lesion occurring in the periocular region and discuss its clinical features, imaging characteristics, and surgical management.

Respiratory Epithelial Adenomatoid Hamartomas and Chondroosseous Respiratory Epithelial Hamartomas of the Sinonasal Tract: A Case Series and Literature Review

Background

Respiratory epithelial adenomatoid hamartomas (REAH) and chondroosseous respiratory epithelial (CORE) hamartomas are rare sinonasal/nasopharyngeal lesions first characterized in 1995. Although REAH and CORE hamartomas are benign, nonneoplastic lesions, awareness and recognition of these lesions are important because they can be confused grossly and microscopically with more threatening sinonasal tumors.

Methods

This report presents two cases of REAH and one case of a CORE hamartoma. The literature regarding REAH and CORE hamartomas is reviewed, and their distinction from related entities of the sinonasal tract and nasopharynx is discussed.

Conclusions

Misdiagnosing REAH or CORE hamartoma as either inverted papilloma or adenocarcinoma may lead to far more aggressive surgical intervention then is necessary.

Successful Treatment of Extensive Squamous Cell Carcinoma of the Conjunctiva and Upper Eyelid Skin With Topical Therapy Alone

This study reports a case of extensive periocular squamous cell carcinoma of the conjunctiva, extending into the superior fornix, over the upper eyelid margin, and involving the superficial layers of the eyelid skin up to the eyebrow, that was successfully treated solely with topical therapy.

Giant Orbital Hydrocystoma in Children: Case Series and Review of the Literature

OBJECTIVE

To describe the clinical features, ancillary diagnostic studies, and treatment outcomes in a cohort of pediatric patients with giant orbital hydrocystomas.

DESIGN

Retrospective case series.

PARTICIPANTS

Pediatric patients with giant orbital hydrocystomas treated in the practice of one surgeon (PDL).

METHODS

A retrospective review of the clinical charts of pediatric patients with orbital hydrocystoma was performed and diagnostic information collected. Results were reviewed and compared with reported clinical data in the literature.

MAIN OUTCOME MEASURES

Clinical presentation and histopathological findings of pediatric orbital hydrocystomas.

RESULTS

Three pediatric cases of giant orbital hydrocystoma were encountered, each with an unusual feature, including deep orbital location, occurrence following trauma, and eccrine pathology.

CONCLUSION

Giant orbital hydrocystomas may present in the pediatric population. Ophthalmologists should be cognizant of this entity when evaluating a child with a large, cystic orbital mass.

Case report of a congenital lingual leiomyomatous hamartoma: new epidemiologic findings and a review of the literature

We present an unusual case of a lingual leiomyomatous hamartoma, along with a current literature review of this previously under reported lesion. Described is a case of a 5 month-old male presenting with a posterior midline tongue mass and surgical excision yielded pathology consistent with a leiomyomatous hamartoma. A comprehensive literature review revealed thirty-nine cases of leiomyomatous hamartomas, a number much greater than previously reported. We conclude that these rare lesions are notably twice as common as previously reported and have equal gender predilection.

Oncogene-induced telomere dysfunction enforces cellular senescence in human cancer precursor lesions

In normal human somatic cells, telomere dysfunction causes cellular senescence, a stable proliferative arrest with tumour suppressing properties. Whether telomere dysfunction-induced senescence (TDIS) suppresses cancer growth in humans, however, is unknown. Here, we demonstrate that multiple and distinct human cancer precursor lesions, but not corresponding malignant cancers, are comprised of cells that display hallmarks of TDIS. Furthermore, we demonstrate that oncogenic signalling, frequently associated with initiating cancer growth in humans, dramatically affected telomere structure and function by causing telomeric replication stress, rapid and stochastic telomere attrition, and consequently telomere dysfunction in cells that lack hTERT activity. DNA replication stress induced by drugs also resulted in telomere dysfunction and cellular senescence in normal human cells, demonstrating that telomeric repeats indeed are hypersensitive to DNA replication stress. Our data reveal that TDIS, accelerated by oncogene-induced DNA replication stress, is a biological response of cells in human cancer precursor lesions and provide strong evidence that TDIS is a critical tumour suppressing mechanism in humans.

Loss of interferon regulatory factor 5 (IRF5) expression in human ductal carcinoma correlates with disease stage and contributes to metastasis

INTRODUCTION

New signaling pathways of the interleukin (IL) family, interferons (IFN) and interferon regulatory factors (IRF) have recently been found within tumor microenvironments and in metastatic sites. Some of these cytokines stimulate while others inhibit breast cancer proliferation and/or invasion. IRFs, a family of nine mammalian transcription factors, have multiple biologic functions that when dysregulated may contribute to tumorigenesis; most well-known are their roles in regulating/initiating host immunity. Some IRF family members have been implicated in tumorigenesis yet little is still known of their expression in primary human tumors or their role(s) in disease development/progression. IRF5 is one of the newer family members to be studied and has been shown to be a critical mediator of host immunity and the cellular response to DNA damage. Here, we examined the expression of IRF5 in primary breast tissue and determined how loss of expression may contribute to breast cancer development and/or progression.

METHODS

Formalin-fixed paraffin-embedded archival breast tissue specimens from patients with atypical ductal hyperplasia (ADH), ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) were examined for their expression of IRF1 and IRF5. Knockdown or overexpression of IRF5 in MCF-10A, MCF-7 and MDA-MB-231 mammary epithelial cell lines was used to examine the role of IRF5 in growth inhibition, invasion and tumorigenesis.

RESULTS

Analysis of IRF expression in human breast tissues revealed the unique down-regulation of IRF5 in patients with different grades of DCIS and IDC as compared to IRF1; loss of IRF5 preceded that of IRF1 and correlated with increased invasiveness. Overexpression of IRF5 in breast cancer cells inhibited in vitro and in vivo cell growth and sensitized them to DNA damage. Complementary experiments with IRF5 siRNAs made normal mammary epithelial cells resistant to DNA damage. By 3-D culture, IRF5 overexpression reverted MDA-MB-231 to normal acini-like structures; cells overexpressing IRF5 had decreased CXCR4 expression and were insensitive to SDF-1/CXCL12-induced migration. These findings were confirmed by CXCR4 promoter reporter assays.

CONCLUSIONS

IRF5 is an important tumor suppressor that regulates multiple cellular processes involved in the conversion of normal mammary epithelial cells to tumor epithelial cells with metastatic potential.

Corneal chromoblastomycosis caused by Cladophialophora carrionii after cataract surgery

We describe a case of corneal chromoblastomycosis with Cladophialophora carrionii in a 69-year-old woman 4 weeks after clear corneal cataract surgery. The patient presented with right eye pain and decreased visual acuity of 20/100. Examination showed a deep posterior stromal keratitis accompanied by a dense fibrinous anterior chamber reaction. An aqueous tap was performed, and the patient was treated with topical, systemic, and intracameral antifungal and antibiotic agents. The infection was resistant to medical therapy and the course further complicated by secondary pupillary block glaucoma. After 10 days, a therapeutic penetrating keratoplasty was performed. The patient remained asymptomatic 20 months after the initial presentation, with corrected distance visual acuity restored to 20/40. To our knowledge, is the first reported case of corneal chromoblastomycosis with C carrionii. Early surgical treatment may be necessary to eradicate Cladophialophora species.

Optic nerve sheath fenestration in cryptococcal meningitis

A patient with acquired immunodeficiency syndrome (AIDS) developed crytpococcal meningitis, complicated by papilledema and severe progressive visual loss despite medical therapy. Bilateral optic sheath fenestration resulted in significant improvement in vision and resolution of papilledema. Histopathologic evaluation of the optic nerve sheath demonstrated numerous cryptococci. Optic nerve sheath fenestration may be an effective treatment method when high intracranial pressure is contributing to visual loss, even in the presence of involvement of the optic nerve sheath by the fungus.

Inflammatory pseudotumor (plasma cell granuloma) of the temporal bone

We report the case of a 41-year-old man who presented with progressive right-sided ear pressure, otalgia, hearing loss, tinnitus, and intermittent otorrhea. Computed tomography and magnetic resonance imaging detected a soft-tissue mass in the right mastoid with intracranial invasion and erosion through the tegmen tympani and mastoid cortex. Histopathologic examination was consistent with an inflammatory pseudotumor (plasma cell granuloma). These lesions rarely occur in the temporal bone. When they do, they are locally destructive and can erode bone and soft tissues. Aggressive surgery is recommended as a first-line treatment, with adjunctive steroid or radiotherapy reserved for residual or refractory disease. Our patient subsequently experienced multiple recurrences, and his treatment required all of these modalities. At the most recent follow-up, he was disease-free and doing well.

Primary alveolar soft part sarcoma of fibula demonstrating ASPL-TFE3 fusion: a case report and review of the literature

Alveolar soft part sarcoma is a rare soft tissue tumor typically affecting young adults. These tumors are most often seen in the deep soft tissues of the extremities and patients generally present with advanced disease. Primary bone involvement is extremely rare and has only been reported in seven cases. This is the first case of alveolar soft part sarcoma in bone documenting the ASPL-TFE3 gene product. Herein, we report a rare presentation of alveolar soft part sarcoma presenting as a primary bone neoplasm involving the proximal fibula in a 41-year-old woman.

Preoperative fine needle aspiration cytology diagnosis of microcystic adenoma of the pancreas: fact or fiction? A report of 2 cases

BACKGROUND

Microcystic adenoma is an uncommon benign neoplasm involving the pancreas that usually affects older populations. These neoplasms often enlarge to significant sizes, causing symptoms of obstruction and discomfort.

CASES

We report 2 cases of microcystic adenoma of the pancreas in which an accurate diagnosis could not be rendered on cytology material alone. Bench fine needle aspiration (FNA) biopsy performed on the resection specimen in one of the cases had a higher cellular yield because a different technique was used to prepare the slide.

CONCLUSION

A preoperative diagnosis can be helpful in guiding the care of the patient, thereby increasing the importance of a diagnosis to distinguish between a benign vs. malignant process. These case reports demonstrate the difficulty of obtaining diagnostic cells in microcystic adenoma, highlight the use of FNA to increase cellular yield and emphasize the importance of correlating radiologic findings with aspiration of abundant watery fluid from cystic pancreatic masses to make a definitive diagnosis.

Peripheral granular cell odontogenic fibroma

Peripheral odontogenic fibroma is a rare lesion that arises on the gingiva and can clinically mimic a variety of reactive lesions, benign neoplasms, and metastases. We describe a symptomatic lesion arising on the mandibular gingiva of a 58-year-old female with no history of trauma or dental disease in the area. An excisional biopsy showed the lesional stroma to contain numerous polyhedral granular cells with occasional interspersed islands of inactive odontogenic epithelium. We believe this to represent the fourth case of peripheral granular cell odontogenic fibroma to be reported in detail in the literature.

Lentigo maligna of the eyelid a rare finding in African Americans

OBJECTIVE

To report the case of a 48-year-old African American man with lentigo maligna of the left lower eyelid.

DESIGN

Interventional case report.

PARTICIPANTS

One patient with lentigo maligna of the left lower eyelid.

METHODS

We report the clinical presentation, histopathologic and immunohistochemical features, and treatment of an African American man with lentigo maligna of the eyelid. The current literature regarding this uncommon neoplasm in African American patients also is reviewed.

MAIN OUTCOME MEASURES

Histopathologic and immunohistochemical diagnosis and clinical evaluation for recurrence.

RESULTS

An excisional biopsy revealed lentigo maligna. An extensive literature search revealed no definitive reports of lentigo maligna or lentigo maligna melanoma of the eyelid in an African American patient.

CONCLUSIONS

Although extremely rare, lentigo maligna may involve ocular adnexal skin in African Americans. Awareness and recognition of this premalignant lesion will aid in early diagnosis and treatment and eventually may improve prognosis.

A t(12;17) in an extraorbital giant cell angiofibroma

We report a case of a 43-year-old male who presented with a large soft-tissue neck mass 7 years ago. A diagnosis of giant cell angiofibroma (GCA) was made on the basis of light microscopy and immunohistochemical studies. Chromosome analysis showed a male karyotype with t(12;17)(q15;q23),del(18)(q21) in all 20 cells analyzed. This cytogenetic abnormality in GCA is different from the t(17;22)(q22;q13) found in related lesions, such as giant cell fibroblastoma and solitary fibrous tumor, none of which has a specific chromosomal abnormality. Our case is the second case of GCA with chromosomal aberrations. To the best of our knowledge, this is the first case of GCA with t(12;17) occurring as an extra-orbital mass.

Fine-needle aspiration cytology of alveolar rhabdomyosarcoma utilizing ThinPrep® liquid-based sample and cytospin preparations: A case confirmed by FKHR break apart rearrangement by FISH probe

Rhabdomyosarcoma is the most common childhood sarcoma that occurs in the soft tissues of the head and neck, genitourinary system, and extremities. While this tumor may also be seen in young adults, it is distinctly unusual to see this neoplasm beyond the fifth decade. The use of fluorescence in situ hybridization (FISH) probes on fine-needle aspiration material for chromosomal analysis to detect chromosomal translocations are not well established. Herein we present a case of metastatic alveolar rhabdomyosarcoma originating in the nasal sinus and recurring in the neck of an adult man 5 yr after his initial presentation. The ThinPrep smear demonstrated isolated malignant tumor cells similar to his previous histologic material. The cytologic findings of alveolar rhabdomyosarcoma were confirmed utilizing a dual color break apart FISH probe which identified the FKHR translocation on the cytospin preparation prepared from a ThinPrep vial and processed as a cytospin preparation. In addition to routine and immunocytologic staining, we demonstrate that aspirated tumor cells can be analyzed using a FISH probe to identify specific chromosomal abnormalities.

PENETRATING TRAUMA ASSOCIATED WITH FINDINGS OF MULTIPLE EVANESCENT WHITE DOT SYNDROME IN THE SECOND EYE

PURPOSE

To report a case of sympathetic ophthalmia (SO) resembling multiple evanescent white dot syndrome (MEWDS).

METHODS

Retrospective chart review.

RESULTS

A 17-year-old girl with a ruptured globe in the right eye underwent prompt primary repair and vitrectomy, scleral buckling, and silicone oil infusion 3 weeks later. Eight weeks after injury, she presented with visual loss in the left eye. Fundus examination in the left eye disclosed optic disk swelling and well-circumscribed, 100 to 500 microm diameter gray-white lesions at the level of the retinal pigment epithelium (RPE) posterior to the equator, sparing the fovea. On fluorescein angiography, the lesions appeared as areas of blocked choroidal fluorescence in the arterial phase and were associated with dye leakage in a wreathlike pattern during venous filling. Dye leakage occurred at the optic disk. Visual field testing showed depressed central sensitivity and an enlarged blind spot in the left eye. The patient was treated with prednisone and underwent diagnostic enucleation of the right eye. Histopathology showed rare choroidal granulomata and pigment phagocytosis. Vision improved to 20/20 in the left eye, and the window defects persisted. Visual field testing 6 months later was normal. One month after discontinuing prednisone, new areas of RPE hypopigmentation developed. Two weeks later, choroidal inflammation recurred and periphlebitis developed.

CONCLUSION

This case indicates that SO can mimic MEWDS.

Subglottic ductal cysts associated with complete tracheal ring deformity: coexistence of two rare airway abnormalities with fatal outcome

Subglottic cysts are rare and may cause airway obstruction. Most cases are acquired secondary to endotracheal intubation, even short-term, particularly in the premature neonate. Complete tracheal rings are rare anomalies associated with tracheal stenosis. To our knowledge, the two have not been reported coexisting. A 16-month-old ex-premature boy was found unresponsive, with his tracheostomy tube dislodged. Tracheomalacia, subglottic stenosis, and a laryngeal cyst had been diagnosed shortly after birth, and the cyst was surgically treated at that time. At autopsy, a complete tracheal ring was noted in the subglottic region, above the tracheostomy site, and the tracheal diameter was markedly decreased in this area. In addition, multiloculated cysts were present at that level, arising from both anterolateral tracheal walls. These completely occluded the airway. To our knowledge, this is the first case of a combination of tracheal ring anomaly and subglottic cysts. Pediatric pathologists must be aware of iatrogenic lesions associated with care of the premature neonate, particularly as the age of viability continues to decrease.

Adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct: a case report

OBJECTIVES

To present the clinical presentation, workup, surgical approach, and pathological findings of the first case report of a patient with adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct.

STUDY DESIGN

Retrospective review of the records of a case of adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct.

METHODS

The clinical presentation, workup, surgical approach, and pathological findings were reviewed.

RESULTS

A 51-year-old man presented with a 10-year history of recurrent epiphora of the right eye. At dacryocystorhinostomy a small lesion was visualized within the lumen of the lacrimal sac. A biopsy specimen was consistent with adenocarcinoma. En bloc resection was accomplished using a lateral rhinotomy and medial maxillectomy. The final specimen showed adenocarcinoma ex-pleomorphic adenoma. The patient was given postoperative radiation therapy. He was free of disease 16 months after treatment.

CONCLUSIONS

Lacrimal sac tumors should be considered in the differential diagnosis of chronic epiphora. Management of nasolacrimal adenocarcinoma requires complete surgical resection. Radiation treatment in and of itself is not curative but may be useful as adjuvant therapy. Carcinoma ex-pleomorphic adenoma can develop in the lacrimal sac and nasolacrimal duct.

Liquid-based vs. conventional smears in fine needle aspiration of bone and soft tissue tumors

OBJECTIVE

To compare the accuracy of fine needle aspiration cytology of bone and soft tissue tumors utilizing ThinPrep (TP) (Cytyc Corporation, Boxborough, Massachusetts, U.S.A.) vs. conventional smears (CS).

STUDY DESIGN

Fine needle aspiration cytology from bone and soft tissue tumors was processed and assessed for cellularity, nuclear and cytoplasmic preservation, cellular architecture and stromal background with both the TP liquid-based smear technique and conventional methods.

RESULTS

An accurate diagnosis was made in 13% of TP cases as compared to 64% in CS cases.

CONCLUSION

CS of fine needle aspiration sample is far superior to TP in diagnosing tumors of bone and soft tissues. Preservation of cytoplasmic features and cellular architecture was superior in conventionally prepared smears.

Carcinoma ex oncocytic Schneiderian (cylindrical cell) papilloma

INTRODUCTION

This study reviews the clinicopathologic features of carcinoma presenting in oncocytic Schneiderian papilloma (OSP; cylindrical cell papilloma), a rare histologically distinctive papilloma sharing features with inverted papilloma.

MATERIALS AND METHODS

Nine cases of carcinoma ex OSP (1970-1990), six from the files of the Armed Forces Institute of Pathology (Washington, DC) and three from the surgical pathology files, Presbyterian-University Hospital and Eye and Ear Institute (Pittsburgh, PA), were studied. One case was previously reported. Clinical data were obtained from the patients' medical records. All available histologic slides were reviewed.

RESULTS

The patients (eight men, one woman) ranged in age from 48 to 83 years (mean age, 74 years). The carcinoma and OSP were synchronous in eight patients. In one case, the carcinoma occurred 8 years after OSP was diagnosed on biopsy. The presenting manifestations included nasal obstruction, "polyps," epistaxis, and proptosis. Radiographically, a sinonasal mass was present, often with extension to adjacent sites and bone destruction. Most patients received postoperative irradiation. Of six patients with follow-up, four died of carcinoma and two were alive without disease at 1.5 and 7 years, respectively. The types of carcinoma were: squamous cell (n = 6), high-grade mucoepidermoid (n = 2), and sinonasal undifferentiated (n = 1). Histologic transition was observed between carcinoma and dysplastic/benign OSP in eight cases.

CONCLUSION

Demonstration of histologic continuity between carcinoma and dysplastic OSP epithelium in eight of our nine cases indicates origin of carcinoma from the OSP, rather than a coincidence of the two neoplasms. Although histologically benign, OSP should be totally excised at diagnosis because of a potential for malignant transformation. This is a US government work. There are no restrictions on its use.

Epithelial myoepithelial carcinoma of the parotid gland

EMEC is a clear-cell tumor of salivary gland origin. Since it was first recognized as a distinct salivary gland malignancy in 1956, sporadic cases have been reported. A case of an EMEC in a parotid gland of a 77-year-old man is described. The clinical and histopathologic features of this unusual neoplasm, as well as a description of the immunohistochemistry and current management of this uncommon entity are presented.

Inverted schneiderian papilloma of the sinonasal tract in children

Inverted schneiderian papilloma of the sinonasal tract is an uncommon lesion in adults and is even less common in children. Nine cases occurring in the pediatric age group have been reported in the literature. We describe two more childhood cases of inverted schneiderian papilloma, one occurring in a 15-year-old girl and the other in a 10-year-old boy. This lesion in children behaves similarly to that in adults. When treated by intranasal surgery, it usually recurs. With this report we would like to illustrate the diagnostic and differential diagnostic elements of this lesion and increase the awareness of this entity in the pediatric age group.