Carcinoma

Synchronous verrucous carcinoma and inverted papilloma of the lacrimal sac: Case report and clinical update

October 23, 2013     Cheryl Gustafson, MD; Eugene Einhorn, MD; Mary H. Scanlon, MD; Kenneth E. Morgenstern, MD; Paul J. Howlett, MD; Noam A. Cohen, MD, PhD
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Abstract

Inverted papilloma is a benign epithelial tumor of the nasal cavity. It is known to coexist with malignancy in 5 to 13% of cases, with squamous cell carcinoma being the most common malignancy. Another associated malignancy, one that is extremely rare, is verrucous carcinoma. To the best of our knowledge, no case of verrucous carcinoma occurring alone or in association with another neoplasm has been described in the nasolacrimal system. We report a case of synchronous verrucous carcinoma and inverted papilloma of the lacrimal sac in a 47-year-old man. The patient presented with epiphora, nasal obstruction, swelling of the left medial canthus, and drainage of a foul-smelling fluid from the left nostril. Computed tomography and magnetic resonance imaging detected the presence of a large mass occupying the left nasal cavity and sinuses with extension into the nasopharynx. In addition, bony invasion of the anteroinferomedial wall of the left orbit was noted with extension of the tumor into the orbit itself, which resulted in lateral displacement of the left medial rectus muscle. The patient underwent endoscopic debulking of the left sinonasal lesion. Of note, the surgery had to be completed in stages because of excessive blood loss. Histopathologic examination of the intranasal component of the tumor identified it as an inverted papilloma. One month after the intranasal resection, a left dacryocystectomy was performed; histopathologic examination revealed that an invasive verrucous squamous cell carcinoma had arisen within the inverted papilloma.

Case report: Paraneoplastic neurologic syndrome associated with squamous cell carcinoma of the tonsil

October 23, 2013     Jeffrey R. Janus, MD; Sivakumar Chinnadurai, MD; Eric J. Moore, MD
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Abstract

Paraneoplastic syndromes include a variety of disorders that affect the neurologic, endocrine, mucocutaneous, hematologic, and other systems as a result of neoplastic disease. Although their presentations vary, syndromes occur when tumor antigens exhibit cross-reactivity to similar antigens expressed by these systems. The antigens in the nervous system are called “onconeural” antigens. Although many disorders are associated with a comparatively high incidence of paraneoplastic neurologic syndromes, only a few cases have been associated with squamous cell carcinoma (SCC) of the tonsil. We report the case of a 69-year-old man who initially presented with weakness and spastic gait. He was subsequently found to have a characteristic paraneoplastic tractopathy on thoracic magnetic resonance imaging. The subsequent workup and operative intervention identified a T2N0M0 SCC of the tonsil. Following resection, the patient's overall symptoms were significantly alleviated, and his gait improved. A thorough literature search yielded no other report of a tonsillar SCC with associated paraneoplastic thoracic spine tractopathy.

Undifferentiated thyroid carcinoma

October 23, 2013     Lester D.R. Thompson, MD
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Histologically, undifferentiated thyroid carcinomas show a variety of patterns, from sheet-like, storiform, fascicular, angiomatoid, and meningothelial to solid, exhibiting extensive lymph-vascular invasion.

Acantholytic squamous cell carcinoma of the maxilla: Unusual location and aggressive behavior of a rare histologic variant

September 18, 2013     Ozan Bagis Ozgursoy, MD; Ozden Tulunay, MD; Sami Engin Muz, MD; Gaffar Aslan, MD; Babur Kucuk, MD
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Abstract

Acantholytic squamous cell carcinoma (ASCC) of the mucosal membranes has been documented sporadically. The highly aggressive behavior of a mucosal ASCC arising in the oral cavity has been recently reported. To the best of our knowledge, only 1 autopsy case of maxillary ASCC previously has been reported in the literature. We pre-sent what we believe is only the second case of maxillary ASCC. Our goal is to emphasize the aggressive behavior of this tumor in order to add weight to the argument that the prognosis is poor.

Endometrial carcinoma metastatic to the retromolar pad

September 18, 2013     Hisham Hatoum, DDS; Bruno C. Jham, DDS, MS, PhD; Karen Garber, DMD; Jaime S. Brahim, DDS, MS; Mark A. Scheper, DDS, PhD
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Abstract

Metastatic carcinoma from the female genitalia to the oral mucosa is exceptionally rare, with only 11 such cases having been previously reported in the English-language literature. We describe a new case in a 65-year-old woman with a history of endometrial carcinoma who presented with swelling of the retromolar pad. Radiographic examination showed slight opacities and irregular trabecular bone in the left posterior mandible. Following an incisional biopsy, histologic examination and immunohistochemical studies revealed glandular adenocarcinoma with positivity for progesterone receptor, estrogen receptor, and cytokeratin 7. The patient was referred to her primary care physician for comprehensive treatment. This case illustrates the value of considering cancer metastasis in the differential diagnosis of an oral swelling, particularly in a patient with a history of cancer.

Thyroglossal duct cyst carcinoma: Case report and review of the literature

September 18, 2013     David W. Jang, MD; Andrew G. Sikora, MD, PhD; Anatoly Leytin, MD
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Abstract

Well-differentiated thyroid carcinoma of a thyroglossal duct cyst (TGDC) is a rare entity, found in about 1% of all TGDCs. Diagnosis is usually made incidentally after a Sistrunk procedure. Options for further therapy include total thyroidectomy, T4 suppression therapy, and radioactive iodine ablation. In a patient with a normal-appearing thyroid gland and no evidence of metastatic disease, the treatment course is controversial. The recent literature emphasizes the identification of risk factors that may prompt the clinician to pursue more aggressive treatment. We present the case of a 35-year-old woman who was found to have a 1-cm midline neck mass that showed atypical cells on fine-needle aspiration. Histologic analysis after a Sistrunk procedure revealed a small focus of papillary carcinoma within the TGDC. The patient subsequently underwent total thyroidectomy with no evidence of carcinoma on histologic examination.

Practical applications of in-office fiberoptic transnasal esophagoscopy in the initial evaluation of patients with squamous cell cancer of the head and neck

September 18, 2013     Robert W. Dolan, MD; Timothy D. Anderson, MD
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Abstract

We conducted a study to analyze the effectiveness of transnasal esophagoscopy (TNE) as an alternative to operative endoscopy (OE) for the evaluation of primary head and neck cancers and for the surveillance of synchronous esophageal cancers. Our study population was made up of 96 consecutively presenting patients-75 men and 21 women, aged 45 to 88 years (mean: 64)-who were treated at our institution for squamous cell cancer of the head and neck. Of this group, 42 patients had been evaluated with TNE and 54 with OE. More OEs were performed in patients with an unknown primary (26 vs. 3). Incidental findings on TNE included 3 cases of gastritis, 2 cases each of hiatal hernia and esophagitis, 1 case of Barrett esophagus, and 1 inlet patch. No incidental findings were reported during OE. Primary cancers were biopsied by TNE through a port on the endoscope in 4 patients; 2 of these cancers were in the tongue base, 1 in the hypopharynx, and 1 in the aryepiglottic fold. After the initial visit, patients in the TNE group waited significantly fewer days for their endoscopy than did those in the OE group (median: 6.5 vs. 16; p < 0.05). Conversely, patients in the OE group waited significantly fewer days for treatment following endoscopy (median: 12 vs. 20; p < 0.05). However, there was no significant difference between the TNE patients and the OE patients in the total number of days comprising their entire course of management, from the initial visit to definite treatment (median: 27.5 and 33 days, respectively; p = 0.7). We conclude that TNE is a reasonable alternative to OE for the initial screening for synchronous esophageal cancers in patients with squamous cancers of the head and neck. OE is preferred for the initial workup of unknown primary cancers and for large tongue base cancers. The rate of detection of clinically relevant incidental findings is higher with TNE. Biopsy is possible during TNE for all subsites within the upper aerodigestive tract.

Lymphoepithelial carcinoma of the parotid gland, a very unusual tumor: Case report and review

September 18, 2013     Natarajan Anantharajan, MRCS, MCh; Nagamuttu Ravindranathan, FRCS, FDRCS; Pathmanathan Rajadurai, MBBS, FRCPA
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Abstract

Lymphoepithelial carcinoma (LEC) of the parotid gland is rare. When it does occur, it is usually seen in Asians and Greenland Eskimos. An association with Epstein-Barr virus (EBV) infection has been documented. We report a case of EBV-associated LEC of the parotid gland in a 30-year-old Chinese woman. The patient underwent a total parotidectomy with preservation of the facial nerve, followed by postoperative radiotherapy. She recovered well without complications or recurrence. We present this case in view of the rarity of LEC, which has prevented extensive study of its clinical course, optimal treatment options, and overall prognosis.

Mucoepidermoid carcinoma presenting as a large cyst of the parotid gland in HIV disease

July 21, 2013     Nelson Goldman, MD; Sania Shuja, MD; Raafat Makary, MD; Reginald L. Griffin, MD
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Abstract

Cystic lesions of the parotid gland may be the presenting symptom in human immunodeficiency virus (HIV)-positive patients. The most common lesion is the benign lymphoepithelial cyst. Malignant lesions may also be associated with-or be hidden by-a cystic mass. We report a case of mucoepidermoid carcinoma in a 40-year-old HIV-positive woman who presented with a large cystic mass of the parotid that had been previously misdiagnosed as benign on several fine-needle aspiration biopsies. On our histologic examination, the true pathologic nature of the lesion was revealed. We suggest that an image-guided fine-needle aspiration biopsy of the thickened wall of cystic masses of the parotid may be more diagnostic than a random sampling of the contents.

Wrong egg in the usual nest: Thyroid papillary carcinoma within a branchial cleft cyst

July 21, 2013     Mustafa Sagit, MD; Ayhan Gokler, MD; Istemihan Akin, MD; Unsal Han, MD
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Abstract

Branchial cleft cysts are the most common lesions to arise laterally in the neck. Ectopic thyroid tissue within a branchial cleft cyst is rare, and a papillary carcinoma arising from this tissue is extremely rare. We present a case of a lateral neck cyst representing a primary papillary carcinoma that arose in ectopic thyroid tissue within a branchial cleft cyst in a 41-year-old woman. After the mass was surgically excised, thyroid ultrasonography, thyroid scintigraphy, and whole-body F18-fluorodeoxyglucose-positron emission tomography/computed tomography detected no abnormality. The negative findings notwithstanding, surgery on the thyroid gland was planned, but the patient refused it. Therefore, she was followed up with ultrasonography and scintigraphy for 5 years, during which time she exhibited no evidence of recurrence. Total thyroidectomy is still the primary option in such cases, but when it cannot be performed for any reason, vigilant follow-up is essential.

Metastatic choriocarcinoma: A rare presentation as a neck mass

June 11, 2013     Hilmi Alper Senkal, MD; Taner Yilmaz, MD; and Ahmet Bulent Sozeri, MD
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Abstract

Testicular carcinoma metastatic to the neck is rare. Even more rare is a finding of choriocarcinoma as a neck mass without any sign of a primary testicular tumor, as only a few cases have been reported in the literature. We describe a new case that occurred in a 29-year-old man who presented with a neck mass. Fine-needle aspiration biopsy identified the tumor as a malignant epithelial neoplasm. Radiologic findings indicated the presence of a systemic metastasis of a tumor to the chest and abdomen, as well as the neck. Findings on an incisional biopsy of the neck mass were consistent with a choriocarcinoma. The testicles were normal on palpation and ultrasonography. The patient was diagnosed with metastatic choriocarcinoma with an unknown primary, and he was started on chemotherapy. On the second day of treatment, which was 25 days after his referral to our clinic, he died of respiratory insufficiency.

Oropharyngeal squamous cell carcinoma metastatic to lower-extremity soft tissues: A case report and literature review

June 11, 2013     Jason M. Samuelian, DO; Brandon J. Fisher, DO; Larry C. Daugherty, MD; and Usha A. Babaria, MD
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Abstract

A 52-year old man was referred to our service for evaluation after being diagnosed with oropharyngeal squamous cell carcinoma. Contrast-enhanced computed tomography (CT) revealed a mass in the left tonsillar pillar, as well as submental lymphadenopathy. The extent of tumor infiltration was assessed by fluoro-2-deoxyglucose positron emission tomography scans, which showed increased uptake in the tumor bed and a suspicious-looking lymph node near the right hilum. No other signs or symptoms of distant metastasis were evident at that time, and the patient was treated with induction chemotherapy followed by chemoradiation. Several weeks after treatment completion, the patient returned, complaining of right medial foot edema. CT of the right lower extremity revealed multiple high-attenuation masses in the soft tissues of the right leg and foot, including a mass in the medial plantar region of the foot. Approximately 15 to 20% of patients with oropharyngeal squamous cell carcinoma develop distant metastasis throughout the course of the disease. Soft-tissue metastases from oropharyngeal cancers are rare, however, particularly when they present in the absence of widespread metastasis. A review of the current head and neck tumor literature describes soft-tissue metastases in less than 10% of patients with known distant metastases. Metastasis to distal regions such as the lower extremities has rarely been observed but should be included in the differential diagnosis for patients presenting with lower-extremity pain or edema.

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