We present a case of malakoplakia presenting as a lesion in the oropharynx of an elderly smoker. In this case a clinical diagnosis of carcinoma of the pharynx was made, biopsy revealed the nature of the lesion and management was radically altered.
Background. Spindle cell lipoma (SCL) is a benign lipomatous tumour, typically occurring in the posterior neck, shoulder or upper back of elderly males. They compose of fat, CD34 positive spindle cells, and ropey collagen on a myxoid matrix. This case highlights a rare presentation of SCL and the need for pre-operative diagnosis. Case Report. A 63-year-old gentleman presented with a pre-existing left supraclavicular mass that had recently increased in size. FNA and CT Scans were performed and results discussed in the mutidisciplinary team meeting. Excisional biopsy was recommended. Radiology. CT neck showed a left supraclavicular mass of fatty density with fine internal septations. A low-grade liposarcoma could not be excluded. Histopathology. FNA was indeterminate. Histology of specimen showed bland spindle cells with no evidence of malignancy. Immuno-histochemistry showed SCL with CD34 positivity and negative staining on CDK4 and p16. Management. Excision biopsy of the mass was performed which was technically difficult as the mass invaginated around the brachial plexus. The patient recovered well post-operatively with no neurological deficits. Conclusion. Spindle cell lipoma is a rare benign tumour and a pre-operative diagnosis based on the clinical context, imaging and immuno-histochemistry is crucial to management.
A 39-year-old man presented to a neck lump clinic with a twomonth history of a lump on the right side of his neck. Following fine needle aspiration, excision biopsy was performed and revealed partial effacement of the architecture with some remaining reactive follicles. There was focal proliferation of plasmacytoid dendritic cells and there were scattered atypical mononuclear and multinucleate Hodgkin-like cells in the interfollicular areas (top left). Immunohistochemistry showed that these cells were CD20, CD30 and MUM1 positive, whereas CD3 showed large numbers of reactive T cells. The plasmacytoid dendritic cells were negative for CD20 and BCL2. Immunohistochemistry for the Epstein-Barr virus was negative. Although the immunophenotype was not entirely typical, the diagnosis was that of classical Hodgkin lymphoma with an interfollicular pattern. His staging positron emission tomography-computed tomography (PET-CT) scan showed glucose-avid lymphadenopathy in the right neck and in the palatine tonsils bilaterally, as well as in the lingual tonsil, more prominent on the right (bottom). The patient underwent bilateral tonsillectomy. Histology showed reactive lymphoid tissue with follicular hyperplasia without evidence of infiltration by lymphoma (top right). The patient was considered to have favourable stage 1 disease and treated with two cycles of doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) and 20 Gy involved field radiotherapy. Knowledge of the tonsillar histology enabled considerable reduction of the radiation field. An end-of-therapy PET-CT showed complete metabolic remission.
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