Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor that is derived from C cells of the thyroid gland. It is a rare aggressive tumor, known to metastasize to lymph nodes, liver, bones, and lungs. A 41-year-old female, who presented with a breast mass, was initially diagnosed with invasive ductal carcinoma. She was also found to have a thyroid mass which was later diagnosed as MTC. On a rereview of the breast pathology, the morphologic features were strikingly similar to the MTC. Further investigation revealed that this was in fact a very rare case of MTC that had metastasized to the breast. We have identified 20 cases of MTC metastasizing to the breast in the literature that supports its occurrence as a real possibility. Albeit rare, medullary thyroid carcinoma should be considered in the differential diagnosis of a breast mass.
Plasma cell granulomas (PCGs) or inflammatory pseudotumors are nonneoplastic lesions that consist of predominantly antibody-secreting plasma cells and innate immune cells such as neutrophils, macrophages, and eosinophils. Unlike in multiple myeloma, the plasma cells are polyclonal and present in a spindly fibroblast-rich stromal background. These lesions mainly occur in the lungs; however, they can arise in other organs. PCGs from the gingiva are extremely rare, and a proper diagnosis is crucial to treat these patients further. These tumors have an increased number of plasma cells that are immunoreactive with CD138 and are polyclonal for kappa and lambda light chains, confirming these proliferations’ nonneoplastic nature. Surgical resection with clear margins, when possible, is the primary choice of treatment. Radiation and anti-inflammatory steroid therapy are other therapeutic approaches. Critical and careful examination by a pathologist is necessary to rule out plasma cell neoplasms. Here, we report a rare occurrence of gingival PCG in an elderly male.
Casestudy: Dedifferentiated solitary fibrous tumor is a rare malignant subtype of the common benign mesenchymal neoplasm with fibroblastic differentiation known as solitary fibrous tumor (SFT). These account for less than 2% of all soft masses; and about 20% of SFTs turn aggressive. They feature bland spindle cells creating a classic “pattern-less pattern” in collagenous stroma with prominent staghorn vessels. They can dedifferentiate into a biphasic tumor with low grade areas that are spindle cell rich and high-grade areas with epithelioid cells, mitotic figures and necrosis. Here we present an 84-year-old female who came from an outside institution for a pathology review. The patient’s clinical history was lacking and biopsies from the right lower and middle lobes of the lung, azygous and hilar lymph nodes were investigated. The pathology revealed multiple areas with epithelioid cells that were pleomorphic and had high nuclear to cytoplasmic ratio. These areas also contained numerous mitotic figures, necrosis and giant cells; with lymphovascular space invasion. There was a clear demarcation between the epithelioid area and an area rich in spindle cells. The spindled areas revealed a fascicular architecture with intervening sclerotic stoma and prominent rounded and dilated blood vessels. Immunohistochemistry analysis of the epithelioid and spindle cell areas were positive for STAT6. Additional testing for CD34 was diffusely positive in the spindle cell component and only focally positive in the high-grade portion of the tumor. Ki-67stain was utilized to estimate the proliferative index which was up to 80 percent in the high-grade epithelioid component and about 15% in the spindle cell portion. These morphological and histochemical findings were consistent with the diagnosis of a dedifferentiated solitary fibrous tumor.
Introduction/Objective Pernio or chilblains, is a rare condition associated with small pruritic swellings of the extremities triggered by low temperature. Generally, the patients experience a burning and itching sensation in the affected areas that increases with return to warm temperature. The underlying risk factors include autoimmune disorders and cryoglobulinemia. Herein we present an unusual and rare case of chilblains that evaded diagnosis for few years. The general concepts of analytical and clinical evaluations of this condition, with emphasis on accurate diagnosis of gammopathies, along with the importance of laboratory evaluations and accurate interpretation of laboratory results will be discussed. Methods Multiple laboratory investigations (CBC, electrolyte analysis, serum protein electrophoresis, free light chain analysis) were pursued together with skin biopsies. Additionally, CT scan under low radiation exposure and bone marrow biopsy were followed. Plasma sample viscosity at room temperature was evaluated. Results Skin biopsies from right anterior thigh and left arm revealed leucocytoclastic vasculitis with normal perivascular staining for C3 and fibrinogen. Serum sample at room temperature exhibited increased viscosity and protein electrophoresis identified a highly elevated IgG kappa monoclonal globulin peak whose concentration increased upon warming and dilution of the sample, suggesting that agglutinin precipitated at cold temperature (below body temperature). Analysis of free light chains revealed elevated concentration of kappa light chain whose concentration also increased upon warming the serum sample. Whole body CT scan and bone marrow biopsy analysis further identified lytic lesions. These investigations established the diagnosis of plasma cell myeloma (CD138 staining) with expression of monoclonal immunoglobulin precipitating at temperatures below that of the body. Conclusion Given the above findings this case of chilblains can be classified as cryoglobulinemia vasculitis. The importance of attention to details (e.g. characteristics of serum samples), accurate interpretation of laboratory findings and analysis clinical information are all very crucial to arrive at a differential diagnosis.
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