Hemophagocytic Lymphohistiocytosis Secondary to Unknown Underlying Hodgkin Lymphoma Presenting with a Cholestatic Pattern of Liver Injury

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon disease that often presents with nonspecific findings. A high index of suspicion is necessary to make a prompt diagnosis and prevent fatal disease. A 45-year-old man presented with fever, hypotension, abdominal pain, nausea, and vomiting. Imaging showed hepatosplenomegaly and laboratory tests revealed pancytopenia, increased ferritin, and a cholestatic pattern of injury with elevated alkaline phosphatase and total bilirubin. Due to a history of Crohn disease, systemic lupus erythematous, and rheumatoid arthritis, the patient was on immunosuppressants, including infliximab. After multiple negative cultures, persistent fever, and days of empiric broad spectrum antibiotics, our differential shifted to fever of unknown origin. A liver wedge biopsy revealed areas of sinusoidal dilatation with enlarged, activated macrophages containing erythrocytes and intracytoplasmic iron, consistent with hemophagocytosis due to HLH. The portal tracts showed mixed lymphoplasmacytic inflammation, a prominent bile ductular reaction, periportal fibrosis, and scattered large cells with occasional binucleation and prominent nucleoli. These cells stained positive for Epstein-Barr virus encoding region in situ hybridization, PAX5, CD15, and CD30, and hepatic involvement by classic Hodgkin lymphoma was diagnosed and determined to be the cause of the HLH and cholestatic pattern of injury. Simultaneously, a bone marrow biopsy showed diffuse involvement by Hodgkin lymphoma with a similar staining pattern. Aggressive treatment failed and the patient succumbed to multiorgan failure. HLH is a rare, potentially fatal disease, with nonspecific signs and symptoms, and should be considered in any patient presenting with fever and pancytopenia, especially if they are immune compromised.

Clinico- pathologic presentation of hypersensitivity pneumonitis in Egyptian patients: a multidisciplinary study

Background

Hypersensitivity pneumonitis (HP) is a common diffuse parenchymal lung disease in Egypt which can be difficult to recognize due to the dynamic symptoms & associated environmental factors.

Methods

Forty-three Egyptian patients were enrolled in this study, presenting with dyspnea and cough, predominant ground-glass opacity (GGO) in high-resolution computed tomography (HRCT) where lung biopsy was needed to establish the diagnosis.

Results

The age range was 15 to 60 years. Females represented 90.7% (39 patients) while 9.3% (4 patients) of our patients were males. History of contact with birds was detected in 9 (20.9%) patients. Most of our patients (60.5%) didn’t have exposure history, and only 8 patients (18.6%) were living in geographic areas in Egypt that are known for the exposure to environmental etiologic factors (cane sugar exhaust fumes). The most common HRCT pattern was GGO with mosaic parenchyma in 18 patients (41.86%), followed by GGO with centrilobular nodules in 9 patients (20.93%), then isolated diffuse GGO in 5 patients (11.62%), GGO with traction bronchiectasis in 4 patients (9.3%), GGO with consolidation in 3 patients (6.97%), GGO with reticulations in 2 patients (4.65%), and GGO with cysts in 2 patients (4.65%). The most common histologic finding was isolated multinucleated giant cells in 38 patients (88.3%) commonly found in airspaces (24 patients) and less commonly in the interstitium (14 patients), followed by interstitial pneumonia and cellular bronchiolitis in 36 patients (83.7% each), interstitial ill-formed non-necrotizing granulomas in 12 patients (27.9%), fibrosis in 10 patients (23.2%), and organizing pneumonia pattern in 4 patients (9.3%).

Conclusion

The diagnosis of HP presenting with predominant GGO pattern in HRCT requires a close interaction among clinicians, radiologists, and pathologists. Some environmental and household factors may be underestimated as etiologic factors. Further environmental and genetic studies are needed especially in patients with negative exposure history.

Clinico-pathologic presentation of hypersensitivity pneumonitis in Egyptian patients: a multidisciplinary study

Background: Hypersensitivity pneumonitis (HP) is a common diffuse parenchymal lung disease in Egypt which can be difficult to recognize due to the dynamic symptoms & associated environmental factors. Methods: Forty-three Egyptian patients were enrolled in this study, presenting with dyspnea and cough, predominant ground-glass opacity (GGO) in high-resolution computed tomography (HRCT) where lung biopsy was needed to establish the diagnosis. Results: The age range was 15 to 60 years. Females represented 90.7% (39 patients) while 9.3% (4 patients) of our patients were males. History of contact with birds was detected in 9 (20.9%) patients. Most of our patients (60.5%) didn’t have exposure history, and only 8 patients (18.6%) were living in geographic areas in Egypt that are known for the exposure to environmental etiologic factors (cane sugar exhaust fumes). The most common HRCT pattern was GGO with mosaic parenchyma in 18 patients (41.86%), followed by GGO with centrilobular nodules in 9 patients (20.93%), then isolated diffuse GGO in 5 patients (11.62%), GGO with traction bronchiectasis in 4 patients (9.3%), GGO with consolidation in 3 patients (6.97%), GGO with reticulations in 2 patients (4.65%), and GGO with cysts in 2 patients (4.65%). The most common histologic finding was isolated multinucleated giant cells in 38 patients (88.3%) commonly found in airspaces (24 patients) and less commonly in the interstitium (14 patients), followed by interstitial pneumonia and cellular bronchiolitis in 36 patients (83.7% each), interstitial ill-formed non-necrotizing granulomas in 12 patients (27.9%), fibrosis in 10 patients (23.2%), and organizing pneumonia pattern in 4 patients (9.3%). Conclusion: The diagnosis of HP presenting with predominant GGO pattern in HRCT requires a close interaction among clinicians, radiologists, and pathologists. Some environmental and household factors may be underestimated as etiologic factors. Further environmental and genetic studies are needed especially in patients with negative exposure history.

Atypical papillary lesions after core needle biopsy and subsequent breast carcinoma

Background: Papillary lesions of the breast cause diagnostic problem because papillary structures are found in benign and malignant processes. Core needle biopsy is important to make an initial diagnosis, but it still has potential pitfalls. Comparison between core needle biopsy and excisional biopsy can predict the possibility of malignant change in atypical papillary lesions.

Objective: Evaluate the concordance between core needle biopsy and excisional results in atypical papillary lesions of the breast.

Materials and methods: The pathology database of University of Texas Medical Branch at Galveston, USA was searched for patients with atypical papillary lesions at core needle biopsy who subsequently underwent surgical excision. Pathology reports from the excisional biopsies was also examined to assign each case to one of three categories, downgrade to benign papilloma, no change (remained atypical papillary lesion), and upgrade to carcinoma. The mammograms and ultrasounds were reviewed for each case. They characterized the lesions according to multiple imaging criteria.

Results: Twenty-four patients with atypical papillomas at core biopsy subsequently underwent surgical excision. The lesions were downgraded to benign papilloma in 25%, remained atypical papillary lesion in 33%, and upgraded to carcinoma in 42%. On mammographic presentations (n = 23), masses were in 61%, architectural distortion in 4.3%, mass with calcifications in 9%, mass with architectural distortion and calcifications in 4.3%, calcifications alone in 17.4%, and architectural distortion and calcifications in 4.3%. On ultrasound findings (n = 21), solid masses were in 90%, intracystic masses in 10%, peripheral in locations in 81%, and subareolar in location in 19%.

Conclusion: Due to the high upgrade rate of atypical papillary lesions to carcinoma (42%), excision of all atypical papillary lesions with wide excision margin is recommended for cases with pathologic diagnosis of atypical papillary lesion on core-needle biopsy.

Comparative effects of cocaine and cocaethylene on alveolar epithelial type II cells

Abuse of cocaine (COC) and alcohol have been among the leading causes of non-prescription drug-related deaths in the USA and are known to cause acute and chronic lung diseases. The co-abuse of COC and alcohol results in the production of an active metabolite, cocaethylene (CE). The effects of COC and its metabolites on the respiratory system have been scarcely studied. This study was aimed at comparing the toxic effects of eqimolar concentration (1 mM) of COC and CE on alveolar epithelial type II cells. This was performed by measuring cell growth, viability, clonogenic activity, cell cycle and reactive oxygen species (ROS) generation. The treatment of CE and COC resulted in a significant inhibition of cell proliferation with the formation of an average of three colonies which measured about 1.74×10(-15) m each and 25 colonies each of about 5.73×10(-15) m, respectively, while untreated cells yielded 31 colonies of 8.75×10(-15) m (p<0.05). The treatments of CE and COC resulted in the reduction of the growth fraction of alveolar epithelial type II cells without significant decrease in viability. In addition, there was an approximately twofold increase in ROS generation as compared to the controls (p<0.05). Therefore, CE-induced inhibition of cellular proliferation may contribute to the pathogenesis of diffuse alveolar damage in co-abusers of COC and alcohol.

Intraductal papilloma of the breast in association with preoncogenic gene of breast cancer

We reported a case of an African American woman who went to the hospital with palpable right breast lump with bloody nipple discharge at University of Texas Medical Branch at Galveston. The modalities of breast imagings included mammography and ultrasonography. The method used for viral identification was Linear Array HPV genotyping test. Intraductal papilloma revealed as high density tubular or rounded lobular masses with partially circumscribed, obscured margins and clustered punctate microcalcifications on mammograms. Ultrasound showed as intraductal masses with dilated ducts. The core biopsy demonstrated duct filled with papillary lesion and post excision revealed intraductal papilloma. HPV DNA types 16, 33, 58 and 71 were detected after use of Linear Array HPV genotyping test.

Lymph node involvement in immunohistochemistry-based molecular classifications of breast cancer

BACKGROUND

Prognosis and treatment options differ for each molecular subtype of breast cancer, but risk of regional lymph node (LN) metastasis for each subtype has not been well studied. Since LN status is the most important predictor for prognosis, the aim of this study is to investigate the propensity for LN metastasis in each of the five breast cancer molecular subtypes.

METHODS

Under an institutional review board-approved protocol, we retrospectively reviewed the charts of all pathologically confirmed breast cancer cases from January 2004 to June 2012. Five subtypes were defined as luminal A (hormone receptor positive, Ki-67 low), luminal B (hormone receptor positive, Ki-67 high), luminal human epidermal growth factor receptor 2 (HER2), HER2-enriched (hormone receptor negative), and triple negative (TN).

RESULTS

A total of 375 patients with complete data were classified by subtype: 95 (25.3%) luminal A, 120 (32%) luminal B, 69 (18.4%) luminal HER2, 26 (6.9%) HER2-enriched, and 65 (17.3%) TN. On univariate analysis, age (<50), higher tumor grade, HER2+ status, tumor size, and molecular subtype were significant for LN positivity. Molecular subtype correlated strongly with tumor size (χ(2); P = 0.0004); therefore, multivariable logistic regression did not identify molecular subtype as an independent variable to predict LN positivity.

CONCLUSIONS

Luminal A tumors have the lowest risk of LN metastasis, whereas luminal HER2 subtype has the highest risk of LN metastasis. Immunohistochemical-based molecular classification can be readily performed and knowledge of the factors that affect LN status may help with treatment decisions.

In situ hybridization for the detection of hepatitis C virus RNA in human liver tissue

In situ hybridization (ISH) enables visualization of specific nucleic acid in morphologically preserved cells and tissue sections. Detection of the HCV genomes in clinical specimens is useful for differential diagnosis, particularly between recurrent HCV infection and acute cellular rejection in transplant specimens. We optimized an ISH protocol that demonstrated sensitivity and specificity for detecting genomic and replicative form of HCV RNA in tissue biopsies. Digoxigenin (Dig)-labelled sense and anti-sense riboprobes were synthesized using a plasmid containing a fragment of the highly conserved HCV noncoding region as a template. The efficiency of the Dig-labelled riboprobes in detecting genomic and replicative-intermediate HCV RNA was analysed in 30 liver biopsies from patients infected or uninfected with HCV in a blinded study. A Huh7 cell line that stably replicates genome-length HCV RNA was developed to be used as a positive control. Negative control riboprobes were used in parallel to evaluate and control for background staining. The anti-sense probe detected HCV RNA in 20/21 specimens from HCV-infected liver tissues obtained from patients and in 0/9 samples from patients with non-HCV-related liver diseases, resulting in a sensitivity and specificity of 95% and 100%, respectively. HCV genomic RNA was variably distributed in tissue sections and was located primarily in the perinuclear regions in hepatocytes. Detection of HCV RNA by our optimized ISH protocol appears to be a sensitive and specific method when processing clinical specimens. It may also be revealing when exploring the pathophysiology of HCV infection by verifying the presence of viral genetic material within heptocytes and other cellular elements of diseased liver tissue. This methodology might also evaluate the response to antiviral therapies by demonstrating the absence or alteration of genetic material in clinical specimens from successfully treated patients.

A t(1;9)(q10;q10) translocation with additional 6q23 and 9q22 rearrangements in a case of chondromyxoid fibroma

Chondromyxoid fibroma (CMF) is a rare cartilaginous tumor of bone. It typically presents in the long tubular bones and to a lesser extent in the small bones of the hands and feet of young adults. To date, several cytogenetic abnormalities have been described in association with CMF. We studied a phalangeal CMF from a 13-year-old female by cytogenetic methods. We found a novel unbalanced translocation between the long arms of chromosomes 1 and 9, resulting in loss of 1p. In addition, rearrangements involving the 6q23 and 9q22 regions were also observed. To our knowledge, this is the first report in the literature describing this novel chromosomal translocation in CMF.

Detection of human papilloma virus subtypes 16 and P16(ink4a) in invasive squamous cell carcinoma of the fallopian tube and concomitant squamous cell carcinoma in situ of the cervix

Squamous cell carcinoma (SCC) of the fallopian tube is rare and often diagnosed postoperatively. Cervical cancer is considered as a long-term sequaele, resulting from sexual transmitted infection with certain common high-risk human papilloma virus (HPV) types. The role of human papilloma virus in the development of the tubal SCC is unknown. We report an unusual case of SCC of the fallopian tube, synchronously occurring with cervical SCC in situ in a 49-year-old patient. Histological examination of the entire endometrium revealed no involvement Both tubal and cervical lesions showed the presence of high risk HPV 16 by PCR and increased expression of p16(INK4a) protein. Both SCC of the fallopian tube and cervical SCC in situ were positive for p63, while the non-involved tubal epithelium was positive for WT-1, but negative for p63. In conclusion, the concomitant occurrence of fallopian tube and cervical SCC can be explained by: (i) the 'field effect' of HPV infection resulting in the concomitant development of primary SCC in various sites of the female genital tract; (ii) the primary fallopian tube SSC metastasizing to the uterine cervix; or (iii) primary cervical SCC metastasizing to the fallopian tube. The detection of HPV 16 and p16(INK4a) in both the fallopian tube and cervicalSCCs strengthens the hypothesis of the 'field effect' of HPV infection.

Immunohistochemical characterization of subtypes of male breast carcinoma

Introduction

Male breast cancer accounts for around 1% of all breast cancer cases but the incidence has risen in recent years. This study aimed to classify the molecular subtypes of male breast cancers based on the expression profile of immunomarkers and to evaluate their association with clinicopathological features and expression patterns of epidermal growth factor receptor (EGFR) and nuclear factor κB (NF-κB).

Methods

A total of 42 cases of male breast carcinoma were examined retrospectively using immunostains for estrogen receptor (ER), progesterone receptor (PR), cytokeratin 5/6 (CK5/6), EGFR, and NF-κB. Human epidermal growth factor receptor 2 (HER2) expression was evaluated by immunostaining and confirmed by fluorescent in situ hybridization (FISH).

Results

The luminal A subtype was the most common subtype in male breast cancer (83%, 35/42), which was followed by the luminal B subtype (17%, 7/42). Basal-like and HER2+/ER- subtypes were not identified in this group. All carcinomas expressed ER and 67% of them were PR+. High nuclear grades were more common in the luminal B subtype (71%, 5/7) than in the luminal A subtype (34%, 12/35). The luminal B subtype carcinomas expressed EGFR (42%, 3/7) and NF-κB (57%, 4/7) more frequently than the luminal A subtype did (17%, 6/35 and 37%, 13/35, respectively).

Conclusions

In our study group, luminal A and B subtypes were the major subtypes of male breast carcinoma. The immunophenotypical features of male breast cancer differ from those of its female counterpart. Luminal B subtype tended to have high nuclear grade and more frequent expression of EGFR and NF-κB.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia is an extremely rare pulmonary lesion, with only 39 cases reported in the literature. We report an additional case and review the literature. The patient is a 41-year-old man with a 5-year history of progressive dyspnea, cough, and wheezing. He was initially diagnosed as having bronchial asthma but did not respond to treatment of bronchodilators and inhaled steroids. Pulmonary function tests showed airflow obstruction. Chest computed tomography revealed a mosaic pattern of air trapping and thickening of bronchial walls. Open lung biopsy showed diffuse proliferation of pulmonary neuroendocrine cells within the bronchiolar epithelium, often bulging into or obliterating the bronchiolar lumen. These cells also breached the basement membrane, forming tumorlets. There was prominent peribronchiolar fibrosis and obliterative bronchiolitis. The pathologic evaluation of lung tissue is currently the gold standard in making a definitive diagnosis of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia, and all the reported cases were diagnosed by either open lung biopsy or lobectomy.

Intranodal palisaded myofibroblastoma

Intranodal palisaded myofibroblastoma (IPM) usually presents as a painless, slow-growing inguinal mass. Our review of 42 cases from 13 publications indicates that two thirds of IPMs occur between the ages of 45 and 55 years, the male-female ratio is 2:1, and there is a lack of ethnic predilection. Grossly, the IPM cut surface shows areas of hemorrhage. Five microscopic features are seen: (a) compressed remnants of lymphoid tissue at the periphery; (b) spindle cells with nuclear palisading; (c) intraparenchymal hemorrhage and erythrocyte extravasation; (d) so-called amianthoid fibers; and (e) intracellular and extracellular fuchsinophilic bodies that stain positive for smooth muscle actin. Immunohistochemically, IPM is positive for smooth muscle actin and cyclin D1 and negative for S100, glial fibrillary acidic protein, CD34, and desmin, and it shows a low proliferative index of Ki-67. Electron microscopy demonstrates features of myofibroblasts and smooth muscle cells. Excellent prognosis is seen after surgical treatment, with an approximately 6% recurrence rate and no malignant transformation.

Immunohistochemical and ultrastructural analysis of a poorly differentiated pediatric age Sertoli–Leydig cell tumor

Ovarian Sertoli-Leydig cell tumors (SLCT) are rare in young women. They are divided into six categories based on the degree of differentiation and the presence of heterologous elements. Less than 15% of these tumors are poorly differentiated. A 14-year-old obese African-American girl presented with amenorrhea, progressive abdominal pain, and increasing abdominal girth. Pelvic CT revealed a 10 x 9 x 9 cm right adnexal mass which was resected successfully. The gross appearance was dark tan and red with central hemorrhage and necrosis. Microscopically, this was poorly differentiated with compact aggregates of moderate size oval to elongated cells separated by zones of edematous stroma containing scattered spindle shape cells. Areas of ill-formed tubules and primitive cords were present. Clusters of Leydig cells were observed. The oval and spindle cells showed multiple mitoses and were diffusely positive for inhibin and patchy but strong positivity for calretinin. Both preoperative and postoperative studies revealed no metastases. Serum alpha-fetal protein (AFP), androgen, and dihydroepiandrosterone sulfate (DHEA-S) were elevated.

Histopathologic and immunohistochemical characterization of a primary papillary thyroid carcinoma in the lateral cervical lymph node

Lymph nodes in the neck are known to occasionally contain benign epithelial inclusions and can be rare primary site of various tumors usually occurring in other organs. Papillary thyroid carcinoma in the lateral neck lymph node with co-existing ectopic thyroid inclusions has not been reported previously. A 41-year-old male patient, who had normal thyroid function and no history of neck irradiation, was seen with a slowly enlarging mass in the right lateral neck. At surgery the cervical mass was found to be separate from the thyroid proper without any attachments in between. Papillary thyroid carcinoma and co-existing thyroid inclusions were identified within the lateral cervical lymph node. Immunohistochemistry detected strong and diffuse cytoplasmic positivity with antibodies against CK19 and CK903 in papillary thyroid carcinoma. Benign thyroid follicles within the lymph node were only weakly and focally stained. Thorough examination confirmed no malignancy in the total thyroidectomy specimen. Furthermore, small foci of metastatic papillary carcinoma were identified in two ipsilateral lymph nodes from neck dissection specimen. These findings suggest development of primary papillary thyroid carcinoma from malignant transformation of benign intranodal thyroid inclusions.

Mimicks of pancreatic malignancy in patients with chronic pancreatitis: correlation of computed tomography imaging features with histopathologic findings

Differentiation of chronic pancreatitis and pancreatic carcinoma can be a clinical and radiologic dilemma. Several patients with chronic pancreatitis can undergo unnecessary major abdominal surgery for benign lesions. This pictorial review illustrates the computed tomographic findings and histopathologic features of lesions mimicking pancreatic neoplasm in patients with chronic pancreatitis. Several benign lesions can simulate pancreatic malignancy in patients with chronic pancreatitis. Knowledge of the computed tomographic appearance of these benign entities is important to prevent unnecessary surgeries.

Cytogenetic and molecular studies of an unusual case of multiple primary alveolar rhabdomyosarcomas: low-level chromosomal instability and reciprocal translocation t(6;11)

Cytogenetic and molecular studies have shown that approximately 80% of cases of alveolar rhabdomyosarcoma (ARMS) have consistent chromosomal translocation of either t(2;13) or t(1;13), resulting in either PAX3-FKHR or PAX7-FKHR gene fusions. However, 20% of the cases diagnosed histologically are negative for these fusion genes. The clinical and pathological properties of the so-called fusion gene negative tumors remain to be defined. We present an unusual case of a 7-year-old boy who developed three separate primary ARMS over a 5-year period, with the first tumor diagnosed at the age of 12 months. The tumors were negative for the characteristic translocations, t(2;13) or t(1;13), but showed evidence of low-level chromosomal instability and a reciprocal chromosomal translocation t(6;11)(q27;q13). PCR amplification of the p53 gene, exons 2-11, followed by DNA sequencing did not detect any germline p53 mutation. These clinical and cytogenetic features have not been reported previously in ARMS. The findings suggest that cytogenetic abnormalities of chromosome 6 may be associated with the development of early onset multiple ARMS in a subgroup of pediatric patients as seen in this case.

Nodular Mucinosis of the Breast: A Case Report With Pathologic, Ultrasonographic, and Clinical Findings and Review of the Literature

Nodular mucinosis is an extremely rare breast lesion. This benign mass usually presents clinically as a poorly circumscribed, subareolar, myxoid mass in young female patients. We report a case of this rare breast lesion and discuss its clinical, radiologic, and histopathologic features. A 21-year-old white woman presented with a mass in the left breast of 6 months' duration. She had never been pregnant or had any history of breast feeding, surgery, trauma, or use of exogenous hormones or a family history of breast cancer. Clinical breast examination demonstrated a 1 cm “rubbery” mass directly under and continuous with the left nipple. The skin that covered the mass had an edematous and irregular appearance without erythema or drainage from the nipple. Ultrasonography demonstrated a 1-cm, nonintraductal, circumscribed, homogeneous, isoechoic mass that was continuous or part of the base of the left nipple. The mass was smooth, with a thin echogenic rim. Doppler flow showed some vascularity. These findings suggested a benign breast lesion, including a fibroadenoma or nipple adenoma. Despite reassurance, the patient desired excision of the lesion. Gross examination revealed a nodular, rubbery-firm, ovoid, pink, polypoid mass that measured 1.5 × 0.9 × 0.8 cm. Microscopic examination showed a well-circumscribed tumor with a nodular appearance, which consisted of an accumulation of pink myxoid tissue and contained spindle cells with bland-appearing nuclei, no mitosis, and mild cellularity. The pink myxoid tissue was stained with Hale colloidal iron and Alcian blue. The Alcian blue stain was removed by pretreatment with hyaluronidase. The spindle cells stained with vimentin and smooth muscle actin; however, they did not express smooth muscle myosin or cytokeratin. This report presents and discusses the pathologic, ultrasonographic, and clinical findings of this rare entity.

Renal cell carcinoma metastatic to Hürthle cell adenoma of thyroid

Metastases to the thyroid gland are a common finding at autopsy in patients who died of malignancy and are often misdiagnosed as primary thyroid neoplasms clinically. We present a patient with a rare, unusual case of renal cell carcinoma (RCC) metastatic to a Hurthle cell adenoma of the thyroid. A 53-year-old woman was admitted to a University of Texas Medical Branch Hospital (Galveston, TX) for a large right thyroid mass that was present for 3 months. A fine needle aspiration of the thyroid mass was performed and interpreted as suggestive of a Hurthle cell neoplasm. A total thyroidectomy revealed Hurthle cell adenoma containing clusters of cytologically atypical cells with clear cytoplasm. Subsequent patient evaluation and computed tomography revealed a renal mass. Left radical nephrectomy was performed at a later date for left renal mass and the microscopic examination confirmed the diagnosis of primary clear cell carcinoma of the kidney. Further studies confirmed that the thyroid mass was metastases from RCC. Although carcinoma of the kidney is responsible in most instances of metastatic disease to the thyroid, metastatic RCC to a thyroid neoplasm is extremely rare, with only two reports found in the English literature. The possibility of metastatic RCC should always be taken under consideration, especially when nests of clear cells are seen infiltrating into the thyroid parenchyma or neoplasm.

Primary Small Cell Neuroendocrine Carcinoma of the Vagina: A Clinicopathologic Study

Context.—Primary small cell neuroendocrine carcinoma of the vagina is extremely rare, and its clinical behavior is aggressive. To our knowledge, 22 patients with this tumor have been reported in the English literature to date.

Objective.—To investigate 3 patients with this tumor clinically and pathologically.

Design.—The pathology database at the University of Texas Medical Branch at Galveston was searched, and 3 cases of primary small cell neuroendocrine carcinoma of the vagina were found. The histologic, immunohistochemical, and ultrastructural profiles of the tumors were investigated. The medical charts of the patients were reviewed, and the patients were followed up.

Patients.—Women with the diagnosis of primary small cell neuroendocrine carcinoma of vagina.

Results.—All 3 patients presented with advanced disease, and 2 patients died within 4 months of the initial diagnosis. One 38-year-old patient was newly diagnosed, and her clinical outcome had not yet been determined. The histologic features of all 3 tumors were similar to those of their pulmonary counterpart. All cases were positive for cytokeratin, chromogranin A, and synaptophysin. The expression pattern of thyroid transcription factor 1 was examined in all 3 patients, of whom 2 were negative and 1 was positive with negative clinical and radiologic thyroid or pulmonary findings. Ultrastructural evaluation showed scattered intracytoplasmic electron-dense neurosecretory granules.

Conclusion.—Primary small cell neuroendocrine carcinoma of the vagina has histologic, immunohistochemical, and ultrastructural features similar to those of its pulmonary counterpart. Because thyroid transcription factor 1 can be positive, it should not be used to differentiate primary from metastatic disease. The current therapies have usually resulted in poor outcomes, and new therapeutic modalities should be explored.

Ventilator-associated pneumonia in patients with adult respiratory distress syndrome: CT evaluation

PURPOSE

To determine the diagnostic accuracy of computed tomography (CT) for pneumonia in patients with adult respiratory distress syndrome (ARDS).

MATERIALS AND METHODS

CT scans were obtained within 1 week of bronchoscopic sampling in 31 patients receiving mechanical ventilation for ARDS for more than 48 hours. Of 11 patients with pneumonia, five developed symptoms less than 11 days after the onset of ARDS (early ARDS). CT scans were rated for pneumonia independently by four radiologists who were unaware of the clinical diagnosis. Diagnostic accuracy was defined by means of the area under the receiver operating characteristic curve, or A2.

RESULTS

Diagnostic accuracy for pneumonia was fair (A2 = 0.69 +/- 0.04 [standard error]) owing to 70% true-negative ratings (vs 59% true-positive ratings). The generalizability coefficient was good (0.79). No single CT finding was significantly different for the presence of pneumonia. Nondependent opacities predominated in 10 (91%) of 11 patients with pneumonia and 12 (60%) of 20 without pneumonia. Nondependent opacities predominated in nine (56%) of 16 patients with early ARDS and 13 (87%) of 15 with late ARDS.

CONCLUSION

CT has fair diagnostic accuracy for ventilator-associated pneumonia in patients with ARDS owing primarily to identification of patients without pneumonia. No single CT sign was significantly different for pneumonia, but dependent atelectasis was more common in patients with early ARDS without pneumonia.

Pulmonary capillary hemangiomatosis: a clinicopathologic review

Pulmonary capillary hemangiomatosis is a locally aggressive benign vascular neoplasm of the lung characterized by the presence of numerous cytologically benign thin-walled capillary-sized blood vessels proliferating diffusely through the pulmonary interstitium, in and around pulmonary vessels and airways. Pulmonary capillary hemangiomatosis is a rare disease characterized by pulmonary hypertension and a slowly progressive clinical course; it is frequently misdiagnosed clinically as primary pulmonary hypertension and veno-occlusive disease. The purpose of this review is to describe the clinical, radiologic, and histologic features of this rare form of pulmonary vascular neoplasm, which may present considerable diagnostic problems to both the clinician and the histopathologist. Fourteen cases of pulmonary capillary hemangiomatosis have been previously reported. In this review we describe the fourth case of pulmonary capillary hemangiomatosis in which the diagnosis was made antemortem, as well as the fourth to undergo lung transplantation.