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Jameson Price
Jameson Price

Atypical 3x2

On dermatoscopy atypical red vessels, branching arborizing vessels and milky red background were seen. Histopathology was consistent with Basal Cell Carcinoma (BCC) of the nodulo-cystic variant. She underwent wide local excision and full thickness skin grafting under general anaesthesia (Figure 1).

Atypical 3x2

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Clear cell hidradenoma (CCH) is an uncommon skin adnexal tumor arising from eccrine glands. Although several kind of skin adnexal tumors arise in the breast tissue, CCH of the breast is an extremely rare entity. Failure to identify its cytomorphologic features and rarity of this tumor may lead to misdiagnosis on fine needle aspiration cytology. Hereby we report a case of 30-year-old female who presented with painless lump in left breast since 10 months. Fine needle aspiration cytology of lump yielded fluid material. On May-Grunwald-Giemsa stained smears, a possibility of atypical breast lesion was considered and patient was advised a biopsy examination. Final diagnosis of CCH was made on histopathologic examination. Awareness of cytomorphologic features of breast CCH will prevent misdiagnosis as malignant or atypical breast lesions and will allow for correct management of the patients.

was no history of preceding trauma, fever, nipple discharge or retraction. There was no family history of breast malignancy. Her menstrual and obstetric history was also not significant. On local examination, there was single well-circumscribed lump measuring 3x2.5 cm in upper outer quadrant of left breast. No skin abnormality was noted. Nipple and areola were also unremarkable. Ipsilateral axillary lymph nodes were not enlarged. Fine needle aspiration cytology (FNAC) was performed with 23G needle. 3 ml straw colored fluid was aspirated and swelling got reduced post aspiration. Cytological diagnosis of atypical breast lesion (C3 lesion) was made and patient was advised biopsy examination. Excision biopsy of lump was performed and mass was sent for histopathological examination. Histological diagnosis of CCH was made. Postoperative course was uneventful. The patient has been disease free since follow-up period of 10 months.

May-Grunwald-Giemsa (MGG) stained FNA smears showed scanty cellularity with few his-tiocytes in hemorrhagic background. The cel-lularity comprised of few round to oval cells in cohesive clusters showing nuclear crowding, mild pleomorphism and lack of bare nuclei (Figure 1). Few clusters showed loosely cohesive cells with abundant eosinophilic cytoplasm (Figure 2). Cytological diagnosis of atypical breast lesion (C3) was made in view of absence of bare nuclei and clusters with nuclear crowding and mild atypia. Gross examination of excised mass showed a soft tissue measuring 2.5x2 cm. Cut section revealed cyst with well-circumscribed intracystic solid component. Hematoxylin and eosin stained sections showed a well-circumscribed intracystic neoplasm. The tumor comprised of lobules separated by thin vascular connective tissue stro-ma with slit-like spaces. The tumor cells were predominantly of two types; most were large round clear cells with eccentric nuclei and other type of cells had a finely granular faintly eosinophilic cytoplasm with round to oval nucleus (Figure 3). No pleomorphism, mitosis or necrosis was observed. No breast ductules were found in the sections examined. Intervening areas showed eosinophilic hyalin-izing stroma. Final diagnosis of CCH was made.

Usually, CCH is difficult to diagnose cytolog-ically and in most studies, cytological diagnosis was either inconclusive or misdiagnosed as breast tumor.1-4 The rarity of this neoplasm and failure to identify its cytomorphological features may lead to misdiagnosis. Being itself rare, cytological features of this lesion are less described in literature. Hence, we describe this case report to highlight cytological dilemma in diagnosis of this entity. We misdiag-nosed it as atypical breast lesion (C3 lesion according to the National Cancer Institute guidelines)67 because of lack of bare nuclei and clusters of round to oval cells with nuclear crowding and mild atypia. CCH typically shows cellular smears on cytology comprising of

7.Goyal P, Sehgal S, Ghosh S, et al. Histopathological correlation of atypical (C3) and suspicious (C4) categories in fine needle aspiration cytology of the breast. Int J Breast Cancer 2013;2013: 965498.

Risks were found to be almost three times higher for people prescribed atypical compared with conventional drugs. However, the overall risk of a clot remained small, with four extra cases estimated per 10,000 patients treated over the course of one year. For people aged 65 and over, the number of extra cases was estimated at 10.

According to the Medicines and Healthcare products Regulatory Agency (MHRA), the following atypical antipsychotics are licensed for use in the UK: amisulpride (brand name Solian), aripiprazole (Abilify), clozapine (Clozaril, Denzapine), olanzapine (Zyprexa), paliperidone (Invega), risperidone (Risperdal, Risperdal Consta) and zotepine (Zoleptil).

A hyperechoic liver lesion on ultrasound can arise from a number of entities, both benign and malignant. A benign hepatic hemangioma is the most common entity encountered, but in patients with atypical findings or risk for malignancy, other entities must be considered.

Fig 1: Computed tomography of the thorax showing a mass inthe lower lobe of the left lung.Fig 2: (a) Hamartoma and in situ squamous cell cancer (H-E x 2).(b) Severe atypical squamous metaplasia and squamous cell carcinomain situ areas in the bronchial epithelium (arrow) (H-E x 100). AbstractCase PresentationDiscussionReferences Discussion Hamartoma is defined as an abnormal mixture of tissueelements, or an abnormal proportion of a singleelement, normally present in an organ. Pulmonaryhamartoma is the most frequent benign neoplasm of thelung, occurring in the parenchyma or sometimes withinthe bronchi.[3] It consists of an admixture of cartilage,loose collective tissue, fat, bone, epithelial clefts, andgland like epithelial aggregates. Depending upon thepredominant component, hamartomas can be dividedinto various subtypes: chondromatous, leiomyomatous,lymphangiomyomatous, adenofibromatous, and fibroleiomyomatous.Chondromatous hamartomas are themost common subtype. Hamartoma is also referred toas fibrolipochondroma.For hamartomas, the age of presentation is 50 to 60years, with a male/female ratio of 3-5/1. In our case, thepatient was a 38-year-old female. The size of hamartomasmay range from 1 cm to larger than 10 cm, but theyare usually smaller than 4 cm.Intraparenchymal hamartomas are usually asymptomatic.However, they may cause complaints like chestpain, dyspnea, cough, and hemoptysis. When the tumorbecomes large enough, it may obstruct a bronchus causingatelectasis and recurrent or persistent pulmonaryinfection. It may sometimes be mistaken for chronicobstructive pulmonary disease, pneumonia, and tuberculosis.Our patient had complaints of cough and dyspneafor more than four years and received medicationwith a diagnosis of chronic bronchial asthma.Diagnostic imaging methods include chest roentgenogram,computed tomography, magnetic resonanceimaging, and bronchoscopy. In general, hamartomasare discovered incidentally on routine chest roentgenogramsas an asymptomatic coin lesion. On chest roentgenograms,intraparenchymal hamartoma appears as asharply outlined, round or oval mass, with lobulation,calcification, peripheral location, and a size smaller than3 cm. Computed tomography helps make a differentialdiagnosis. The major radiographic difficulty with pulmonaryhamartomas is to distinguish them from inflammatoryand metastatic lesions. Hamartomas must be differentiatedfrom small primary bronchogenic carcinomaand solitary pulmonary nodules. Specific popcorn-typecalcification is almost pathognomonic for pulmonaryhamartoma. In our patient, computed tomography ofthe thorax showed a 3x2-cm mass surrounding the leftmain bronchus concentrically at the paramediastinal siteof the lower lobe of the left lung. The mass, descending aorta, and left inferior pulmonary vein were separatedby fat plans, suggesting that the mass was not attachedto the major vessels. With these computed tomographyfindings, the initial diagnosis of the mass included primary lung cancers, bronchial carcinoid tumors, vascular tumors, or benign neoplasms of the lung.Parenchymal hamartomas are not visible on bronchoscopy.However, indirect tumor findings can bevisualized by bronchoscopy. In our patient, computedtomography, bronchoscopy, and transbronchial fineneedleaspiration biopsy were performed preoperatively.Yet, the precise diagnosis was made after histopathologicalexamination.Surgical treatment is the gold standard in intraparenchymalhamartomas including enucleation, lobectomyor sleeve resection, wedge resection, segmentectomy,and pneumonectomy. Endobronchial hamartomas canbe removed successfully through bronchoscopy.[4]We could easily reach the mass through a left posterolateralthoracotomy in our patient. The mass wasfirm, fixed, and immobile. Upon detection of malignancyin frozen section analysis, left lower lobectomy andmediastinal lymph node dissection were performed.Although hamartomas are benign tumors, they mayrarely assume malignant characteristics and may beinvasive to surrounding tissues.[5] Besides, some otherlung pathologies may rarely accompany pulmonaryhamartomas such as bronchiectasis, primary lung cancer,tuberculosis, and metastatic tumors of the lung. Ithas been recommended that patients with hamartomashould be thoroughly evaluated and closely followedupwith respect to the risk for associated synchronousmalignancies.[6,7]In addition to hamartomatous lesions in the fibromuscularstroma, squamous cell carcinoma in situwas determined in the epithelial layer of the bronchialstructures. The tumor was composed of cartilage, fibromyxoidstroma, and adipose tissue with incorporatedbronchiolar epithelium. Areas of severe atypical squamousmetaplasia and squamous cell carcinoma in situwere seen in the bronchial epithelium which was surroundedby the basal membrane (Fig. 2b). Hemorrhageand atelectasis sites were noted in the lung parenchymaaround the lesion. No pathology apart from intensiveanthracosis was observed in lymph node specimens. Based on these findings, the stage of the tumor wasrated as TisN0M0.Tojo et al.[8] reviewed some 50 reports of lung canceraccompanying chondromatous hamartoma and summarizedsome common features as follows: men pastmiddle age, adenocarcinoma, and lung cancer andchondromatous hamartoma present in the same lobe.In our case, the tumor accompanying hamartoma wassquamous cell cancer and it was in situ stage.In conclusion, hamartomas can be seen together withlung malignancies. However, the question whether theaccompanying malignancy is a coincidental occurrenceor is associated with malignant growth in the existinghamartoma layer remains uncertain. It should be keptin mind that hamartomas greater than 4-5 cm, firm,and fixed on manual examination during operationshould raise suspicion for malignancy. In such cases,perioperative histopathological examination is requiredto determine the existence of malignancy and the extentof surgical procedure. AbstractCase PresentationDiscussionReferences References 1) Kim GY, Han J, Kim DH, Kim J, Lee KS. Giant cystic chondroidhamartoma. J Korean Med Sci 2005;20:509-11.2) Sharkey RA, Mulloy EM, ONeill S. Endobronchial hamartomapresenting as massive haemoptysis. Eur Respir J 1996;9:2179-80.3) Kurkcuoglu IC, Demircan S, Kurul IC, Demirag F.Endobronchial lipomatous hamartoma. Asian CardiovascThorac Ann 2005;13:372-3.4) Sahin AA, Aydiner A, Kalyoncu F, Tokgozoglu L, Baris YI.Endobronchial hamartoma removed by rigid bronchoscope.Eur Respir J 1989;2:479-80.5) Poulsen JT, Jacobsen M, Francis D. Probable malignant transformationof a pulmonary hamartoma. Thorax 1979;34:557-8.6) Ribet M, Jaillard-Thery S, Nuttens MC. Pulmonary hamartomaand malignancy. J Thorac Cardiovasc Surg 1994;107:611-4.7) Higashita R, Ichikawa S, Ban T, Suda Y, Hayashi K, TakeuchiY. Coexistence of lung cancer and hamartoma. Jpn J ThoracCardiovasc Surg 2001;49:258-60.8) Tojo Y, Bandoh S, Fujita J, Ishii T, Ueda Y, Okamoto T, et al.A case of synchronous primary lung cancer with hamartoma.Nihon Kokyuki Gakkai Zasshi 2003;41:474-9. [Abstract] AbstractCase PresentationDiscussionReferences Keywords :Carcinoma, squamous cell; hamartoma/surgery; lung neoplasms/surgery Viewed : 10371Downloaded : 2429 Abstract Full Text Full Text PDF Similar Articles E-mail to Author How to Cite Turkish Journal of Thoracic and Cardiovascular Surgery published orginal papers on topics in cardiovascular surgery, cardiovascular anesthesia,cardiology and thoracic surgery. These encompass all relevant clinical, surgical and laboratory specialities, editorials, current and collective reviews, tecnical knowhow papers, case reports, "How to Do It" papers. All copyrights of the articles that published or will be published belongs to Turkish Journal of Thoracic and Cardiovascular Surgery and without permission of editorial board whole articles or any part of articles table pictures and graphics could not be published. Turkish Journal of Thoracic and Cardiovascular Surgery is indexed by Science Citation Index - Expanded (SCIE) 041b061a72


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