Endometrial polyp and endometriosis with atypical stromal cells

Pathology (February 2013) 45(2), pp. 185–205

CORRESPONDENCE Chinese herbal supplements the cause of thyrotoxicosis Sir, Over the counter and via internet dietary supplements to treat the overweight and obese are attractive to many people who desire a ‘magic fix’ for weight loss either in combination with or without lifestyle changes. They are often marketed as natural, perceived to be safe with claims of effectiveness and supported by ‘real’ user claims. Their attraction is they are far less demanding than behavioural changes, strict diets with reduced caloric intake and/or strenuous physical activities. A 41-year-old female was referred to the endocrinology unit by the GP with typical symptoms of hyperthyroidism (palpitations, sweating, feeling hot, tremor, weakness of the arms and legs) recognised following a collapse during an endurance horse marathon ride. The thyroid function results at the time were: TSH <0.05 mU/L (reference range 0.40– 4.00); fT4 35 pmol/L (10–20); fT3 9.5 pmol/L (2.8–6.8). A month later test for thyroid antibodies against TSH receptor was negative, <0.03 U/L (<1.0). All other biochemical test results including potassium (4.1 mmol/L; RR 3.5– 4.5 mmol/L) were within reference interval. On presentation to the endocrinology unit the medications reported by the patient were the contraceptive pill and a Chinese weight loss tablet ‘Qian Zhi Su’ capsules which had been taken for approximately 3 months. The tablets were obtained from a friend who experienced weight loss success and they had obtained the tablets via an internet website and designated Australian agent. The patient had experienced 14 kg loss since the start on the tablets (presentation weight 97.8 kg, BMI 31.6), and also reported a recent viral illness. It was also noted her mother and brother both had diabetes. After ceasing the Chinese tablet the thyroid functions returned to normal within 10 days: TSH 0.06 mU/L (0.3– 4.5); fT4 10 pmol/L (7.0–17.0); fT3 5.1 pmol/L (3.5–6.0). The tablet information is all in Chinese. However, translation of the text shows no reference to the tablets containing thyroid hormones or thyroid tissue. The treating endocrinologist contacted the laboratory for advice and we requested a sample tablet or capsule of the Chinese herbal medication from the patient. In the laboratory the content of the two different coloured (blue and white) capsules in the box were dispersed in 1 mL of normal saline, vortex mixed three separate times and then allowed to rehydrate for one hour. The samples were centrifuged and the supernatant analysed for thyroid function test. The results were: (a) blue capsule fT4 9.1 pmol/L, fT3 39.8 pmol/L, and TSH 0.15 mU/L, and (b) white capsule fT4 19.4 pmol/L, fT3 18.8 pmol/L, and TSH 2.21 mU/L. These results immediately triggered us to think that there was thyroid tissue or extract in the capsule. To determine if this was likely, the solid matter was routinely processed as a cell block (to create a paraffin embedded tissue block) which was then sectioned at 4 mm and stained with haematoxylin and eosin. Admixed within vegetable matter were microscopic fragments (Fig. 1A) composed of thyroidlike follicles containing colloid-like material. Given the clinical scenario, this was in keeping with admixed thyroid tissue. Print ISSN 0031-3025/Online ISSN 1465-3931

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An immunochemistry stain for thyroglobulin was also performed (Fig. 1B) to confirm it was thyroid tissue. This was promptly communicated to the clinical team. There are a number of well-known preparations containing thyroid tissue (porcine mainly) currently available on the market, and these include Armour, Naturethroid, Westthroid, Thyreoidum, Thyreogland, NP Thyroid by Acella, Thyroid-s, Thyroid-D, Erfa, Cinetic, etc., which contain thyroid extract and usually both T4 and T3 hormones. The other common animal source is bovine. Whereas other supplements available on the market only come with T3 extract (Cynomel, Thyrolar, etc.), thyroid-containing herbal medicines such as Dream Shape and Ever Youth have been shown to contain thyroid tissue and be the cause of thyrotoxicosis.1 Thyrotoxicosis has also been reported from ingesting ground beef containing bovine thyroid tissue.2 The case in that publication reported similar findings, 4 kg weight loss in 3 weeks, palpitations, tachycardia and increased sweating. Additionally thyrotoxicosis has been reported from consumption of gullet meat from necks of pigs obtained from slaughterhouse or home slaughter of cows2 and on a larger scale from bovine necks.3 One of the other side effects that was observed with diet medication induced hyperthyroidism was thyrotoxic hypokalaemia periodic paralysis which can cause arrhythmia

Fig. 1 A sample from the Chinese herbal supplement. (A) H&E stain showing thyroid-like follicles and (B) immunohistological stain for thyroglobulin.

2013 Royal College of Pathologists of Australasia

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and death.4 This finding is far more common in Asian patients, with an incidence of 1.8–8.8%, compared with 0.1–0.2% incidence in non-Asian thyrotoxic patients.5 According to Pillitteri et al., 33.9% (44.9% female and 19.8% male) of adults in the USA reported they had used dietary supplements for weight loss.6 The use of such supplements is following the same trend as overweight and obesity, steadily increasing.7 This is due to the ease with which they are available, lower costs, no prescription, privacy in managing own health, etc. Users rarely discuss these with their physicians unless there is a very strong positive outcome or serious health impact. The number of ingredients per supplement has been estimated to average 10 but the range was 1–96 ingredients.8 This capsule is said to contain 11 herbal supplements and makes no reference to any animal tissue, specifically thyroid tissue. The only warning is not to be taken by patients with heart disease. Additionally, the packaging states that the product is approved by the Health Department. It would be safe to assume that the more ingredients present in a supplement the risk of adverse health impact increases, and this may be dependent on the concentration of the toxic compounds. This case clearly illustrates that clinicians must consider herbal supplements as a possible source of thyroid hormones in hyperthyroidism. They should specifically ask patients about supplements in view of the ease of access to such supplements. Conflicts of interest and sources of funding: The authors state that there are no conflicts of interest to disclose. Goce Dimeski*{ Guy Lampe{ Nigel N. Brown* *Pathology Queensland, Chemical Pathology, Princess Alexandra Hospital, {School of Medicine – Southside Clinical School, The University of Queensland, and zPathology Queensland, Anatomical Pathology, Princess Alexandra Hospital, Brisbane, Qld, Australia Contact Dr G. Dimeski. E-mail: [email protected] 1. Ohye H, Fukata S, Kanoh M, et al. Thyrotoxicosis caused by weightreducing herbal medicine. Arch Int Med 2005; 165: 831–4. 2. Parmer MS, Sturge C. Recurrent hamburger thyrotoxicosis. CMAJ 2003; 169: 415–7. 3. Hedberg CW, Fishbein DB, Janssen RS, et al. An outbreak of thyrotoxicosis caused by the consumption of bovine thyroid in ground beef. N Engl J Med 1987; 316: 993–8. 4. Akinyemi E, Bercovici S, Niranjan S, et al. Thyrotoxic hypokalemic periodic paralysis due to dietary weight-loss supplement. Am J Ther 2011; 18: e81–3. 5. Kelly DE, Gharib H, Kennedy FP, et al. Thyrotoxic periodic paralysis. Report of 10 cases and review of electromyographic findings. Arch Intern Med 1989; 149: 2597–600. 6. Pillitteri JL, Shiffman S, Rohay JM, et al. Use of dietary supplements for weight loss in the United States: results of a national survey. Obesity 2008; 16: 790–6. 7. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States. JAMA 2006; 295: 1549–55. 8. Sharpe PA, Granner ML, Conway JM, Ainsworth BE, Dobre M. Availability of weight-loss supplements: Results of an audit of retail outlets in a southeastern city. J Am Diet Assoc 2006; 106: 2045–51.

DOI: 10.1097/PAT.0b013e32835c879e

Pathology (2013), 45(2), February

Pulmonary metastasis from a low grade mucinous appendiceal neoplasm

Sir, Low grade mucinous neoplasms of the appendix that extend through the muscularis propria frequently result in multiple tumourous deposits of gelatinous material on the peritoneal membrane, termed ‘pseudomyxoma peritonei’.1 Although there is significant morbidity secondary to peritoneal dissemination, the risk of metastasis is low. For this reason, various terms have been used to avoid the designation ‘adenocarcinoma,’ including diffuse peritoneal adenomucinosis (DPAM) and low grade appendiceal mucinous neoplasm (LAMN). We report a case of a tumour fulfilling the criteria for DPAM or LAMN with pulmonary metastasis at the time of initial diagnosis. Furthermore, we review other published cases of distant metastases later in the course of disease that highlight an under-recognised phenomenon and suggest that LAMN and DPAM are in fact low grade adenocarcinomas. The patient was a 58-year-old Caucasian man who at 52 years of age experienced intense right lower quadrant pain usually lasting only 5–10 minutes. Due to the intermittent nature of the pain, he did not pursue any medical attention. He was found to have intra-abdominal mucin incidentally during a laparoscopic hernia repair several months after experiencing the abdominal pain, 2 years prior to current admission. Biopsy at that time revealed disseminated peritoneal adenomucinosis most likely of appendiceal origin. It was noted that he had a non-PET avid lesion in his left upper lobe that was thought to be unrelated to his mucinous abdominal neoplasm. The patient delayed treatment for his abdominal tumour. However, 21 months later, because of persistent abdominal symptoms, he underwent right colectomy and cytoreductive surgery, 3 months prior to the current admission. At this time it was noted that there had been an interval increase in the size of the lung tumour. Shortly after his abdominal resection, left video-assisted thoracoscopic surgery with wedge resection was conducted. During the surgery, it was noted that the pleura was normal. The right colectomy specimen demonstrated a dilated appendix containing copious gelatinous mucin. Histologically it was a well-differentiated mucinous tumour with mild dysplasia consistent with an adenoma (Fig. 1A,B). However, there was extension through the muscular wall with numerous peritoneal implants demonstrating a concordant histological appearance (Fig. 1C). The histological findings fit the pathological criteria for DPAM or LAMN, in that there was scant simple mucinous epithelium with little cytological atypia, no mitotic activity, and little if any proliferation, i.e., there was generally only a single cell lining with minimal papillations. The pulmonary lesion was entirely intraparenchymal. It was composed of mucin with scant areas of epithelium, cytologically similar to the appendiceal primary, with minimal cytological atypia (Fig. 1D,E). The scant epithelial component lined the alveolar septa such that the tumour was composed primarily of mucus in a preserved alveolar architecture. The tumour was focally positive for CK7, diffusely positive for CK20 (Fig. 1F), and CDX2, and negative for TTF-1 and napsin A, similar to the peritoneal primary. The similar histological appearance and the immunoprofile confirmed metastasis from the appendiceal primary.

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Fig. 1 Low grade mucinous adenocarcinoma (DPAM/LAMN) metastatic to the lung. (A) Low magnification of the appendiceal lesion demonstrates dilated lumen with a defect in the muscularis (above). There is mucin on the serosal surface (top left). (B) Higher magnification demonstrates a villous neoplasm with low grade dysplasia. (C) The omental metastases were paucicellular, with rare strips of bland epithelium in a mucoid background (centre). (D) The lung metastasis, on low power, showed a mucinous lesion within the parenchyma, adjacent to the pleura. (E) On higher magnification, there were few areas of scant epithelium lining the alveolar spaces. (F) The metastatic epithelium lined alveolar spaces and stained for colonic or appendiceal markers, including cytokeratin 20 (shown).

The classification and terminology of mucinous appendiceal tumours is complicated by confusion about invasive potential of appendiceal mucinous neoplasms, as well as the nature and grading of peritoneal implants. Low grade tumours that seed the peritoneum have been termed low grade mucinous neoplasms or peritoneal adenomucinosis.2,3 Because low grade tumours have a better prognosis, there has been reluctance to utilise the term ‘adenocarcinoma’, despite a significant long-term mortality due to disease.4 Part of the basis for this bias is the concept that there is mechanical disruption of the peritoneum resulting in seeding of benign adenomatous epithelium over the serosa, as opposed to true metastasis. For example, illustrations of invasion through the appendiceal wall by low grade neoplasms have implied that the mechanism is a ruptured diverticulum.2 These unique issues make it difficult to delineate the true nature of appendiceal mucinous tumours, which clearly form a spectrum with high grade adenocarcinomas.5 Specifically, there are mucinous tumours with clearly low grade histology and in situ growth but which present with disseminated peritoneal mucin deposits with the same low grade epithelium, so called ‘pseudomyxoma peritonei’. There are multiple classification systems, from a two-tiered system based solely

on cytological histology, ie., disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis (PMCA), to a multi-tiered system based on the extent of tumour spread and the cytological atypia of the epithelium. The fourtiered system begins with adenoma confined to the appendiceal lumen (mucinous adenoma), and progresses through localised LAMN (low grade appendiceal mucinous neoplasm with low risk of recurrence), LAMN with peritoneal spread (low grade mucinous neoplasm with high risk for recurrence), to invasive (mucinous) adenocarcinoma.2,4,6 One fact not debated is that mucinous tumours confined to the appendix, without invasion (or ‘rupture’) onto the serosa, are benign. However, regardless of tumour extent, low grade mucinous appendiceal tumours tend to disseminate throughout the peritoneum by direct extension, and rarely metastasise via lymphovascular invasion. An alternative view is that all mucinous tumours that seed the peritoneum are indeed adenocarcinomas, with a spectrum of grades typical of most neoplasms. This and previous reports support this hypothesis. Haematogenous spread from mucinous appendiceal neoplasms causing pseudomyxoma peritonei has been reported to the spleen, para-aortic lymph nodes, stomach, lung, and brain.7–9 The degree of cytological atypia of the original appendiceal primary is not well described in all of

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the cases. Specifically, to date, there have been only a few cases of pulmonary involvement from low grade mucinous appendiceal primary, and most cases describe pulmonary involvement long after the initial diagnosis. The earliest report was by Berge, who described pulmonary metastases in a patient with an appendiceal mucocele.10 Later, Mortman et al. reported three patients with pseudomyxoma peritonei and low grade mucinous appendiceal tumour that later developed pulmonary nodules after cytoreduction with peritoneal disease recurrence.11 Specifically, the appendiceal primary appeared to be a low grade tumour for two of three of their patients.11 Another report by Lee et al. also demonstrates pulmonary metastasis with low grade cytological features, similar to the appendiceal primary.12 Additionally, two patients with pulmonary parenchymal metastases of low grade appendiceal tumours were also reported in a series of five patients with low grade appendiceal primaries and thoracic disease involvement.13 The authors reflected similar sentiments regarding the malignant potential of appendiceal tumours with low degrees of atypia, and the misleading classification of these tumours as non-malignant processes.13 Interestingly, there is a case involving a man who presented with multiple recurrent pulmonary metastases 7 and 20 years after his initial diagnosis of appendiceal mucinous adenocarcinoma, indicating the indolence of disease even after haematogenous metastasis.14 However, prolonged survival after metastasis from low grade malignancies is not uncommon, and should not mitigate using a term denoting malignancy, even if low grade. The pulmonary lesions in this patient reflected a higher degree of atypia than his original lesion.14 In conclusion, this case is singular in that the primary appendiceal tumour is clearly of low grade cytological atypia and that the pulmonary metastasis is present at the time of diagnosis. This case demonstrates the haematogenous metastatic potential of appendiceal tumours with bland cytological features, and that lung nodules with low standardised uptake value (SUV) may represent metastatic disease in patients with pseudomyxoma peritonei. Conflicts of interest and sources of funding: The authors state that there are no conflicts of interest to disclose. Lauren Xu Allen Burke Department of Pathology, University of Maryland Medical Center, Baltimore, MD, USA Contact Dr A. Burke. E-mail: [email protected] 1. Panarelli NC, Yantiss RK. Mucinous neoplasms of the appendix and peritoneum. Arch Pathol Lab Med 2011; 135: 1261–8. 2. Misdraji J, Yantiss RK, Graeme-Cook FM, Balis UJ, Young RH. Appendiceal mucinous neoplasms: A clinicopathologic analysis of 107 cases. Am J Surg Pathol 2003; 27: 1089–103. 3. Ronnett BM, Zahn CM, Kurman RJ, Kass ME, Sugarbaker PH, Shmookler BM. Disseminated peritoneal adenomucinosis and peritoneal mucinous carcinomatosis. A clinicopathologic analysis of 109 cases with emphasis on distinguishing pathologic features, site of origin, prognosis, and relationship to ‘pseudomyxoma peritonei’. Am J Surg Pathol 1995; 19: 1390–408. 4. Ronnett BM, Yan H, Kurman RJ, Shmookler BM, Wu L, Sugarbaker PH. Patients with pseudomyxoma peritonei associated with disseminated peritoneal adenomucinosis have a significantly more favorable prognosis than patients with peritoneal mucinous carcinomatosis. Cancer 2001; 92: 85–91.

5. Burke AP, Sobin LH, Federspiel BH, Shekitka KM, Helwig EB. Goblet cell carcinoids and related tumors of the vermiform appendix. Am J Clin Pathol 1990; 94: 27–35. 6. Pai RK, Beck AH, Norton JA, Longacre TA. Appendiceal mucinous neoplasms: Clinicopathologic study of 116 cases with analysis of factors predicting recurrence. Am J Surg Pathol 2009; 33: 1425–39. 7. Mets T, Van Hove W, Louis H. Pseudomyxoma peritonei. Report of a case with extraperitoneal metastasis and invasion of the spleen. Chest 1977; 72: 792–4. 8. Miyashita T, Hoshino E, Imamura T, Okinaga K, Akaoka I, Miyashita H. A case of appendiceal cancer metastatic to the stomach with pseudomyxoma peritonei. J Gastroenterol 1994; 29: 71–5. 9. Yoshida R, Yoshioka K, Yoshitaka H, et al. Pseudomyxoma peritonei of appendiceal cancer with metastasis to the stomach: Report of a case. Surg Today 2002; 32: 547–50. 10. Berge T. ‘Mucocele appendicis’ with pseudomyxoma peritonei and pulmonary metastases. Acta Pathol Microbiol Scand 1964; 60: 483–6. 11. Mortman KD, Sugarbaker PA, Shmookler BM, DeGuzman VC, Soberman MS. Pulmonary metastases in pseudomyxoma peritonei syndrome. Ann Thorac Surg 1997; 64: 1434–6. 12. Lee BY, Kim HS, Lee SH, et al. Pseudomyxoma peritonei: Extraperitoneal spread to the pleural cavity and lung. J Thorac Imaging 2004; 19: 123–6. 13. Geisinger KR, Levine EA, Shen P, Bradley RF. Pleuropulmonary involvement in pseudomyxoma peritonei: Morphologic assessment and literature review. Am J Clin Pathol 2007; 127: 135–43. 14. Khan AA, Tambiah J, Cane P, Lang-Lazdunski L. Prolonged survival in a patient with recurrent pulmonary metastases secondary to mucinous cystadenocarcinoma of the appendix with pseudomyxomatous peritonei. Ann Thorac Surg 2007; 83: 1893–4.

DOI: 10.1097/PAT.0b013e32835c7762

Second case of a fetal sacrococcygeal neuroectodermal cyst in a male newborn Sir, It is well known that during embryogenesis all organ tissues develop from the three primary germ layers: the mesoderm, endoderm, and ectoderm.1 The ectoderm is divided during early embryogenesis into neural plate border and epidermal areas.2 The neural plate border represents the origin of the central and peripheral nervous system. Disruption of the ectodermic morphogenetic events can even result in malformations or tumours, one of the consequences being the formation of neuroectodermal cysts, usually located intracranially. Sacrococcygeal neuroectodermal cyst (SNEC) appears to be an exceedingly rare lesion. Only one case has been previously reported in 1996 by Bloechle et al.3 Herein we report a second case. A 32-year-old previously healthy woman, in her second pregnancy, with no history of abortion or other familial medical history, came to our hospital for a regular gynecological examination. She was in the 16th week of gestation. She asserted she used no drugs and was not exposed to toxic substances or radiation during pregnancy. The ultrasound scan of the fetus revealed a sacrococcygeal cystic tumour diagnosed as sacrococcygeal teratoma. The patient decided to not perform therapeutic abortion. The evolution of her pregnancy was normal, and the patient was monitored on a regular basis. During the 20th week of gestation, the size of the cystic tumour was 51.1
49.6 mm (Fig. 1). Because the tumour was increasing in size, caesarean section was performed without any complications at the 36th week of gestation. Except for the sacrococcygeal tumour, the male newborn weighed 3750 g, was 50 cm long, and did not present any other malformations

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Fig. 1 (A) Sacrococcygeal neuroectodermal cyst is a well defined uniloculated cystic mass, covered with skin. (B) MRI scan examination revealed a well defined mass (C) prenatally diagnosed as a cystic teratoma. Microscopically, the lining epithelium expressed (D) cytokeratin and (E) contained cells with melanotic pigment. (F) The insertion area contained glial ectopic tissue.

or lesions. Routine laboratory examinations revealed no remarkable abnormality. The sacrococcygeal cystic mass was well defined and covered with normal skin. Magnetic resonance imaging scan of the cystic tumour, performed on the third day of his life, revealed a 123
105
89 mm well-defined encapsulated tumour located in the sacrococcygeal region with a homogenous content of fluid, with no signs of involvement of the spinal cord or pelvic organs (Fig. 1). This examination sustained the prenatal diagnosis of sacrococcygeal teratoma (type I, Altman’s classification). Because of the formation of a decubitus ulcer, surgical excision of the tumour was performed on the fifth day of life. During surgery, we noticed that the cyst was attached to the coccyx in the sacrococcygeal area. The insertion area, uncovered with skin, measured 30
20
10 mm, was composed of solid tissue, and presented cranial extension at the level of the promontorium. A total resection of the unopened cystic mass was performed; the solid base and coccyx were removed. The levator and gluteal muscles were reconstructed, and buttock plasty was also performed. A rectal tube was placed into the rectum, and a drainage tube was inserted into the wound; both tubes were removed after 3 days. Macroscopically, the surgical specimen revealed a 780 g unilocular cyst, 120
100
90 mm in diameter, covered by skin and filled with clear serous fluid. The cystic wall was about 2–3 mm thick. The internal surface of the cystic wall had smooth aspect. The previously described sacrococcygeal insertion base was 10–12 mm thick, of hard consistency, and without necrotic or haemorrhagic areas. Microscopically, the flat columnar cyst-lining epithelium alternated with pseudostratified epithelium with micropapillary proliferation, lined with a thin layer of connective tissue. The sacrococcygeal insertion base was composed of vascular-connective and adipose tissue which also contained islets of ectopic glial tissue and tubulo-glandular structures

lined by columnar epithelium with focal melanotic pigment (Fig. 1). These tubulo-glandular structures represented invagination of the cyst-lining epithelium. We did not identify atypia, mitoses, or other types of tissues. Immunohistochemically, the cyst-lining epithelium and the epithelium of the tubular structures from the insertion area were diffusely positive for cytokeratin AE1/AE3 (Fig. 1), vimentin, and S100 protein but did not express epithelial membrane antigen (EMA) or glial fibrillary acidic protein (GFAP). The GFAP marked the ectopic glial tissue from the sacrococcygeal insertion area. Based on localisation, clinicopathological aspect, singlelayered neuroepithelium, presence of melanin-laden cells, and immunohistochemical pattern, the final diagnosis was sacrococcygeal neuroectodermal cyst. It was not a cystic teratoma because of the absence of structures derived from all three germ layers. The lesion was completely removed, post-operative evolution was favourable, and no adjuvant therapy except antibiotherapy was used. Our patient was discharged 10 days after the surgical intervention, and there has been no complication reported 7 months after surgery. Sacrococcygeal neuroectodermal cyst is a malformation which seems to arise from the coccygeal medullary vestige, a pluripotential blastema also called tail bud, or caudal cell mass.4 This embryological structure corresponds to the final closure of the posterior neuropore, and it is the origin of the future caudal spinal cord.4,5 The junctional area between the primary and secondary posterior neural tube corresponds to the lumbosacral region,6 and the caudal structures originate from the tail bud mesenchyme.7 Bloechle et al., performing a review of the literature, concluded that during embryogenesis, the neural tube is located along the entire length of the embryo, but the spinal medulla growth is slower than the vertebral column, ends at the lumbar area, and the closure of the neural tube is located lower, in the

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sacral coccygeal area.3 These are the reasons why disorders of the primary or secondary neurulation, aberrant differentiation of the secondary posterior neural tube, and remnants of the tail bud blastema can lead to spinal neural tube defects.6,8,9 Several hypotheses about the pathogenesis of tail bud malformations have been postulated. For example, Gofflot et al. observed that on the ventral surface of the tail bud the ectoderm is thicker where the ventral ectodermal ridge is formed.7 This ridge is analogous to the apical ectodermal ridge of the limb buds and represents the fusion point between the epithelial and the mesenchymal ridge areas.7 In our case, the thick ectodermic area observed in the cyst base and the presence of ectopic glial tissue only in this insertion area can sustain Gofflot’s hypothesis.7 The coexpression of keratin and vimentin suggests a mesenchymal-epithelial origin, which corresponds to the tail bud. EMA negativity, which is expressed by immature embryonic ectoderm, excludes the disorder of primary neurulation. Based on the correlation between the embryogenetic and the immunohistochemical pattern of this case, we tend to believe that SNEC results from associated disorders of the secondary neurulation (cyst formation) and remnants of the mesenchymal bud tail (mesenchymo-epithelial lining epithelium). Melanocytes can result from the delamination and migration of the neural crests during embryogenesis. SNEC should be differentiated from other cystic lesions such as endodermal cyst, ependymal cyst, anterior meningomyelocystocele, cloacal malformation, and cystic teratoma. Neuroectodermal cysts are mostly located in the third and fourth ventricles of the brain. They are usually diagnosed in adults and seem to originate from the ependymal or choroid plexus epithelium.3 Extraventricular locations, subarachnoidian, into the spinal canal or posterior cranial fossa are extremely rarely reported cases. The endodermal cysts and their colloid variant, which are lined with periodic acidSchiff (PAS) positive intestinal-like epithelium, and also the ependymal cysts lined with the epithelium which expresses S-100, GFAP, and EMA, should be excluded.10 SNEC is lined by columnar neuroepithelium which expresses cytokeratin, vimentin and S-100, can be glial fibrillary acidic protein (GFAP) positive, but it is negative for epithelial membrane antigen (EMA).3 The identification of melanin-laden cells can also sustain the diagnosis. This is the second case of a SNEC in a newborn. The differences between our case and the one described by Bloechle et al.3 are regarding the microscopic view. Bloechle et al. described uniformity of the cyst wall and lining epithelium, with diffuse expression of GFAP, without mentioning EMA negativity. In our case, GFAP marked only the ectopic glial tissue in the insertion area, the other epithelium being negative. EMA negativity is mandatory to sustain the final diagnosis. Cloacal malformations are characterised by the association between spinal neural tube defects and malformations of the external genital organs and/or anal canal malformations,4 which were absent in our case. Cystic sacrococcygeal teratoma, derived from the primitive knot or Hensen’s node, is the most common congenital tumour composed of tissues derived from the three germinal layers, and only a small percentage of them are entirely cystic.11 Altman’s Classification of the Surgical Section of the American Academy of Pediatrics describes four types of sacrococcygeal

teratomas, specifying that all of them can have intraspinal component: type I, predominantly external with a small presacral component; type II, predominantly external with a significant intrapelvic component; type III, partially external with predominantly intrapelvic component and abdominal extension; and type IV, intrapelvic and/or abdominally located tumour without external component.11,12 SNEC is an extremely rare malformation of the tail bud or posterior neuropore and it is a challenge to diagnose it in newborns. Because of the risk of recurrence in case of cystic teratoma, the removal of the coccyx is necessary at the same time as tumour excision. In the first case reported by Bloechle et al.,3 excised in 1996, neurogenic bladder dysfunctions occurred after surgery. In our case, the second case discussed in the literature, no complications or recurrences have been reported 7 months after surgery. Acknowledgements: This work was partially supported by the National Fellowship L’Oreal – UNESCO ‘For Women in Science’. The English language manuscript was polished by Gyorfi Ana-Maria and SPI Global Professional Editing Service. Conflicts of interest and sources of funding: The authors state that there are no conflicts of interest to disclose. Simona Gurzu* Horea Gozar{ Zoltan Derzsi{ Bela Szabo{ Ioan Jung* Departments of *Pathology, {Pediatric Surgery, and zObstetrics and Gynecology, University of Medicine and Pharmacy of Targu-Mures, Romania Contact Dr H. Gozar. E-mail: [email protected]

1. Doss MX, Gaspar JA, Winkler J, et al. Specific gene signatures and pathways in mesodermal cells and their derivates derived from embryonic stem cells. Stem Cell Rev 2012; 8: 43–54. 2. Patthey C, Gunhaga L. Specification and regionalisation of the neural plate border. Eur J Neurosci 2011; 34: 1516–28. 3. Bloechle M, Bollmann R, Wit J, et al. Neuroectodermal cyst may be a rare differential diagnosis of fetal sacrococcygeal teratoma: First case report of a prenatally observed neuroectodermal cyst. Ultrasound Obstet Gynecol 1996; 7: 64–7. 4. Shimokita E, Takahashi Y. Secondary neurulation: Fate-mapping and gene manipulation of the neural tube in tail bud. Dev Growth Differ 2011; 53: 401–10. 5. Pang D, Zovickian J, Moes GS. Retained medullary cord in humans: late arrest of secondary neurulation. Neurosurgery 2011; 68: 1500–19. 6. Saitsu H, Yamada S, Uwabe C, et al. Aberrant differentiation of the axially condensed tail bud mesenchyme in human embryos with lumbosacral myeloschisis. Anat Rec 2007; 290: 251–8. 7. Gofflot F, Hall M, Morris-Kay GM. Genetic patterning of the developing mouse tail at the time of posterior neuropore closure. Dev Dyn 1997; 210: 431–45. 8. Ciraldo AV, Platt MS, Agamanolis DP, et al. Sacrococcygeal myxopapillary ependymomas and rests in infants and children. J Pediatr Surg 1986; 21: 49–52. 9. Bell SM, Schreiner CM, Waclaw RR, et al. Sp8 is crucial for limb outgrowth and neuropore closure. PNAS 2003; 100: 12195–200. 10. Elmadbouh H, Halpin SFS, Neal J, et al. Posterior fossa epithelial cyst: Case report and review of the literature. Am J Neuroradiol 1999; 20: 681–5.

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11. Winderl LM, Silverman RK. Prenatal identification of a completely cystic internal sacrococcygeal teratoma (Type IV). Ultrasound Obstet Gynecol 1997; 9: 425–8. 12. Altman RP, Randolph JG, Lilly JR. Sacrococcygeal teratoma: American Academy of Pediatrics Surgical Section Survey, 1973. J Pediatr Surg 1974; 9: 389–98.

DOI: 10.1097/PAT.0b013e32835c7804

Endometrial polyp and endometriosis with atypical stromal cells Sir, Atypical stromal cells in the female genital tract are consistently encountered in the lower genital tract to the point where they no longer excite particular interest or comment in the literature. They are most probably part of the general indigenous mesenchymal cell population1 and are of significance only when unusually prominent2 or when seen in lesions where their presence raises the spectre of malignancy. This latter circumstance is highlighted especially in polypoid lesions of the cervix, vagina and vulva.3–7 They are far less frequently noted in the upper genital tract, being seen only very infrequently within endometrial polyps or adjacent endometrium7,8 and with vanishing rarity elsewhere; for example, adenomyosis2 or endometrial stromal neoplasms.9 We recently encountered such a case in which not only were these cells present in a non-functional endometrial polyp, as has been previously reported, but also within otherwise typical endometriosis in the right parametrium, an apparently unique expression of this enigmatic process. The patient, a 49-year-old woman, presented with a history of a left salpingo-oophorectomy 2 months previously for an ovarian proliferating (borderline) serous tumour with microinvasion. There was no history of symptoms referable to endometriosis and she had no adjuvant therapy prior to the planned completion hysterectomy and right salpingooophorectomy. At hysterectomy, there was a large multifibroid uterus stuck to the floor of the pelvis by adhesions thought to be endometriotic, but no other lesion visible to the naked eye was present in the pelvic or abdominal peritoneum (i.e., no implants related to the borderline ovarian tumour). The uterus weighed 190 g and contained several typical fibroids, the largest measuring 55 mm across, but no adenomyosis. There was a solitary endometrial polyp 20 mm in length and 7 mm in diameter arising in the fundus. The patient is to be followed clinically both for the excised ovarian neoplasm and the pathology detailed below. Histologically, the eutopic endometrium was late proliferative in phase and unremarkable. The absence of adenomyosis was confirmed. The endometrial polyp was sharply circumscribed and exhibited quite dense and relatively acellular fibrocollagenous stroma, without periglandular hypercellularity (Fig. 1). Numerous scattered atypical stromal cells were seen in the polyp, only occasionally spilling into the immediately adjacent endometrial stroma, but none elsewhere (Fig. 2). The atypical cells were enlarged and occasionally multinucleated with irregular nuclear contour and ample cytoplasm. The nuclei were hyperchromatic but the chromatin condensation appeared smudgy without defined granularity, and

Fig. 1 Endometrial polyp showing sharp circumscription of its margin with proliferative endometrium at right and basal endometrium at bottom, and relatively acellular fibrocollagenous stroma. Scattered atypical stromal cells are seen at right and top left (H&E).

Fig. 2 Interface between endometrial polyp and adjacent proliferative endometrium. Stromal cells with atypical nuclei are confined to the polyp (H&E).

resembled those seen in symplastic leiomyomas. Mitoses and apoptotic bodies were not identified in these atypical cells which were immunoreactive for CD10 (Fig. 3) but not desmin. The myometrial fibroids were histologically benign and no focal symplastic change was present.

Fig. 3 Positive CD10 immunostaining of both normal and atypical endometrial stromal cells in the endometrial polyp.

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A Fig. 5 Endometriotic deposits in right parametrium. Higher power displaying atypical stromal cells (H&E).

(Fig. 6B). No atypical nuclei, mitotic figures or apoptotic bodies were seen. The presence of these atypical stromal cells raised the spectre of a malignant process, specifically mu¨llerian adenosarcoma or endometrial stromal sarcoma. Presentation as an endometrial polyp in a perimenopausal patient is not uncommon for a

B Fig. 4 Florid endometriosis in right parametrium. (A) Deposit adjacent to a large peripheral nerve at lower right and (B) with an incomplete peripheral laminated smooth muscle layer suggesting an occluded thick-walled lymphatic vessel (H&E).

Sections taken from the right parametrium revealed focal deep endometriosis (Fig. 4A) with inactive appearing glands and numerous atypical cells in the stromal component of the endometriosis. Of relevance is the observation that the stroma was rather more fibrous than is usually seen in endometriosis, resembling to some extent the stroma of the endometrial polyp. Furthermore, while there were no endometriotic islands clearly within vascular spaces, some showed laminated smooth muscle around their peripheries, quite strongly suggestive of the media of thick-walled lymphatics (Fig. 4B). One island was adjacent to a large peripheral nerve but not conspicuously in a perineural space. The atypical cells intermingled with the adjacent stromal cells (Fig. 5) without an inflammatory excitation or reactive oedema, indicating they were an integral part of the stroma and they did not extend into the adjacent fibromuscular connective tissue. Stromal hypercellularity, periglandular stromal cuffing, subepithelial stromal condensation, mitoses and apoptotic bodies were again all absent. A third pathological process was identified incidentally in the ampulla of the right fallopian tube, with a solitary swollen plica expanded by endometrial stromal cells without endometrial glandular differentiation of the overlying mucosa Fig. 6A). The endometrial stromal cells had crowded and slightly enlarged nuclei similar to the changes seen in endometrial stromal neoplasms rather than typical endometriosis

A

B Fig. 6 Small mucosal nodule of endometrial stromal cells within the endosalpinx. (A) Low power exhibiting uniformity of gland-free architecture (H&E). (B) Higher power with small ovoid cells with scant nuclei and characterised by a fine meshwork of vessels (H&E).

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mu¨llerian adenosarcoma and the identification of the atypical stromal cells in the parametrial tissue could be construed as evidence of a monoclonal neoplastic process, i.e., metastasis. However, neither the endometrial polyp nor the endometriosis in our case exhibited any features supportive of mu¨llerian adenosarcoma such as stromal hypercellularity, increased mitoses (>3/10 high power fields), periglandular and subepithelial stromal condensation.10 Endometrial stromal sarcoma also required exclusion, given the focal cytological atypia in the stromal cells of the extrauterine lesions and the gland-free endometrial stromal proliferation in the tubal mucosa. Although the malignant stromal cells in endometrial stromal sarcoma are generally small and monomorphic, unusual cases with bizarre stromal cells have been described.9 However, the prominence of endometrial glands as a histological component, as well as an absence of characteristic myoinvasive growth, thin-walled arteriolar vasculature and vascular invasion in association with the endometrial polyp, essentially excluded this diagnosis. An intermediate pathological process between typical endometriosis and an endometrial stromal neoplasm, termed ‘aggressive endometriosis’11 might be closer to explaining the findings in this case. Similarly, malignant mixed mu¨llerian tumour (carcinosarcoma) was not considered likely in the absence of any malignant (carcinomatous) glandular component. The theory of pathogenesis of endometriosis which currently enjoys most widespread acceptance is that of implantation12 and it is curious that the atypical cells should be represented in both the endometriotic deposits and the native endometrium, albeit in a focal polypoid structure. This apparently unique case of atypical stromal cells, identified in an endometrial polyp and in endometriotic deposits in the right parametrium, is regarded as another example of the homology between the eutopic endometrium and ectopic endometriotic deposits13 and does not of itself raise the spectre of malignancy. Careful attention to the morphological features characteristic of a range of malignant endometrial mesenchymal neoplasms should ensure the correct exclusion of a uterine sarcoma. Conflicts of interest and sources of funding: The authors state that there are no conflicts of interest to disclose. Peter Russell*{ Kyaw Lynnhtun* Daniel James{ Andreas Obermair{ *GynaePath, Douglass Hanly Moir Pathology, Macquarie Park, {Department of Obstetrics Gynaecology and Neonatology, University of Sydney, NSW, and zRoyal Brisbane and Women’s Hospital, Qld, Australia Contact Professor P. Russell. E-mail: [email protected] 1. Pitt MA, et al. The nature of atypical multinucleated stromal cells: a study of 37 cases from different sites. Histopathology 1993; 23: 137–45. 2. Rodrigues MI, et al. Atypical stromal cells as a diagnostic pitfall in lesions of the lower female genital tract and uterus: a review and presentation of some unusual cases. Patologia 2009; 47: 103–7. 3. Abdul-Karim FW, Cohen RE. Atypical stromal cells of lower female genital tract. Histopathology 1990; 17: 249–53. 4. Carter J, Elliott P, Russell P. Bilateral fibroepithelial polypi of labium minus with atypical stromal cells. Pathology 1992; 24: 37–9.

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5. Nucci MR, Young RH, Fletcher CD. Cellular pseudosarcomatous fibroepithelial stromal polyps of the lower female genital tract: an underrecognized lesion often misdiagnosed as sarcoma. Am J Surg Pathol 2000; 24: 231–40. 6. Ostor AG, Fortune DW, Riley CB. Fibroepithelial polyps with atypical stromal cells (pseudosarcoma botryoides) of vulva and vagina. A report of 13 cases. Int J Gynecol Pathol 1988; 7: 351–60. 7. Tai LH, Tavassoli FA. Endometrial polyps with atypical (bizarre) stromal cells. Am J Surg Pathol 2002; 26: 505–9. 8. Usubutun A, et al. Atypical endometrial stromal cells related with a polypoid leiomyoma with bizarre nuclei: a case report. Int J Gynecol Pathol 2005; 24: 352–4. 9. Baker PM, Moch H, Oliva E. Unusual morphologic features of endometrial stromal tumors: a report of 2 cases. Am J Surg Pathol 2005; 29: 1394–8. 10. Zaloudek CJ, Norris HJ. Adenofibroma and adenosarcoma of the uterus: a clinicopathologic study of 35 cases. Cancer 1981; 48: 354–66. 11. Scolyer RA, Carter J, Russell P. Aggressive endometriosis: report of a case. Int J Gynecol Cancer 2000; 10: 257–62. 12. van der Linden PJ. Theories on the pathogenesis of endometriosis. Hum Reprod 1996; 11 (Suppl 3): 53–65. 13. Tokushige N, et al. Nerve fibers in ovarian endometriomas. Fertil Steril 2006; 94: 944–7.

DOI: 10.1097/PAT.0b013e32835c87b6

Anastomosing haemangioma of the kidney: a rare morphological variant of haemangioma characteristic of genitourinary tract location Sir, Vascular tumours of the kidney are rare and, although they include a range of benign and malignant lesions, most are benign.1 A recently recognised ‘anastomosing’ variant of haemangioma appears to be a characteristic subtype occurring in the genitourinary tract.1–3 Similar to other vascular tumours of the kidney, it presents as a non-specific solid renal mass on abdominal imaging,1,4 occasionally with urinary tract symptoms, and mimics malignancy, particularly renal cell carcinoma (RCC). Thus pre-operative diagnosis is difficult and the option of conservative management is often not considered. Histologically the anastomosing haemangioma has characteristic features, which should not be mistaken for angiosarcoma. Herein we describe a case of anastomosing haemangioma occurring in the kidney and one of the largest reported to date. A 74-year-old male presented with lower urinary tract symptoms. His medical history included ischaemic heart disease, type 2 diabetes, atrial fibrillation and a previous embolic cerebrovascular event, for which he was on anti-coagulation treatment. On examination, he had a moderately enlarged prostate gland. The patient denied flank pain or macroscopic haematuria. A subsequent computed tomography – intravenous pyelogram (CT-IVP) demonstrated a 5.8
5.1
6 cm irregular enhancing, complex cystic lesion in the right kidney suspicious for RCC (Fig. 1A). He underwent a right laparoscopic nephrectomy and was discharged on post-operative day 3 with a postoperative haemoglobin level of 146 g/L. He re-presented 7 days after surgery, with abdominal pain and blood discharging from his drain site. His haemoglobin had fallen to 104 g/L. A contrast enhanced CT scan confirmed a retroperitoneal haematoma from a lumbar vessel haemorrhage (unrelated to the tumour per se), which was successfully embolised. His anaemia from the delayed haemorrhage preceded a non ST-elevation myocardial infarction. Coronary angiography revealed critical

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Pathology (2013), 45(2), February

Fig. 1 (A) Helical contrast enhanced (arterial phase) computed tomography image of the abdomen with an irregular, enhancing mass of the upper pole of the right kidney. (B) Macroscopic specimen of the kidney, demonstrating a large, well-circumscribed and loculated mass in the upper pole.

stenosis of the right coronary artery. Anti-coagulation was withheld pending coronary artery stenting scheduled for 4 weeks post-embolisation. However, he was re-admitted 2 weeks later with a large embolic cerebrovascular event, from which he died. Nephrectomy tissue was fixed overnight in 10% neutral buffered formalin, embedded in paraffin and stained with haematoxylin and eosin. A panel of immunohistochemical stains was performed using commercially available antibodies on formalin fixed, paraffin embedded (FFPE) sections using an automated immunostainer (Benchmark Ultra; Ventana, USA). Macroscopic examination demonstrated a round, well circumscribed mass composed of firm, fleshy, red-brown tissue and measuring 5.0
4.5
4.0 cm, within the upper pole of the right kidney (Fig. 1B). The tumour abutted but did not invade the renal capsule and showed no evidence of vascular invasion, necrosis or invasion into perirenal fat or renal sinus. Microscopic examination revealed a circumscribed but unencapsulated vascular tumour with alternating cellular and paucicellular areas at low power (Fig. 2A). The latter

comprised loose stromal tissue with ectatic thin-walled blood vessels, while the cellular areas comprised proliferations of capillary sized vessels in an anastomosing pattern (Fig. 2A,B) and some slightly larger sinusoidal vessels within the clusters. The spaces were lined frequently by endothelial cells with hobnail appearance (Fig. 2C), otherwise lacking atypia, multilayering or mitotic activity. There was abundant stromal haemorrhage, occasional thrombi in small vessels and hyaline globules. Involvement of large vessels was not seen, nor was extramedullary haemopoiesis. On immunohistochemistry the cells were confirmed as endothelial, demonstrating positivity for CD31 (Fig. 2D), CD34 and factor VIII-related antigen. Vascular neoplasms are rarely found in the urinary tract, being much more commonly seen in skin and subcutaneous tissue and occasionally in other viscera. While the kidney is the most frequent site, the largest renal series, compiled from the files of several large institutions, comprises only 25 cases.1 The most common renal vascular tumour is haemangioma, while other less common vascular lesions encountered include arterio-venous malformation, haemangioendothelioma,

Fig. 2 (A) Microscopic features, at low power, include alternating cellular and paucicellular areas, (B) small capillary-size blood vessels with focally anastomosing architecture and (C) bland endothelial cells with hobnail appearance (H&E). (D) Immunohistochemical staining for CD31 confirms the endothelial nature of the cells.

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haemangioblastoma and angiosarcoma. A variant of capillary haemangioma with ‘anastomosing’ morphology has recently been described by Montgomery and Epstein2 and appears to comprise a characteristic subset of haemangiomas occurring in the genitourinary tract.2–3 Fourteen renal cases have been described in small series,1–3 and a further four case reports, some given alternate diagnoses, appear to describe the same lesion.5–9 The current case adds to the small number of reported cases. Renal haemangiomas are usually unilateral, solitary lesions occurring in a wide age range, from young adult to elderly, with a median age within the 50-60 year range.1–3 While haemangiomas of the bladder have been found in association with Sturge–Weber syndrome, Klippel– Trenaunay–Weber syndrome and tuberous sclerosis,4 those found in the kidney are not associated with any known syndrome or concurrent presence of non-renal haemangiomas.1 Clinical manifestations include haematuria (particularly for those located at the renal pelvis), flank pain and hypertension,4 although many of these lesions are detected incidentally, either on imaging or at the time of nephrectomy for other tumours.1,3 Haemangiomas of the kidney are generally small: in the series of 14 cases described by Brown et al.,1 size ranged from 0.2 to 3.5 cm, with a mean of 2.0 cm, although cases up to 10 cm have been reported.9 Those identified specifically as anastomosing variant have a mean size of 1.6 cm (range 1.3 to 1.7 cm) in the series reported by Montgomery and Epstein2 and 1.8 cm (0.6 to 5.0 cm) in a subsequent series.3 At 5.0 cm the current case is at the upper limit for size among previously reported cases. Histologically, haemangiomas have been traditionally divided into capillary and cavernous types, analogous to those found elsewhere; those found in renal pyramids or pelvis are classically cavernous.2 The anastomosing subtype has characteristic histological features,1–3 including a vaguely lobulated architecture seen at low power in larger lesions, often associated with a medium calibre vessel, and alternating cellular areas and zones of oedematous or hyalinised stroma. At higher magnification the cellular areas comprise a proliferation of anastomosing sinusoidal capillary-sized vessels, with scattered hobnail endothelial cells. The pattern has been likened to splenic parenchyma, as well as retiform haemangioendothelioma, hobnail haemangioma and sinusoidal haemangioma, all of which tend to occur in skin or soft tissues. Anastomosing haemangiomas are usually sharply delineated, although may be focally infiltrative, and lack features of malignancy, such as mitotic activity, multilayering and atypia of endothelial cells. Vascular thrombi and infiltration of large veins, including renal vein and even inferior vena cava, is not uncommon.2,3,6,5 There is minimal associated lymphocytic infiltration. Extramedullary haemopoiesis and hyaline globules have been described in a minority.2,3 On immunohistochemistry anastomosing haemangiomas display evidence of endothelial differentiation, with positivity for CD31, CD34 and factor VIII-related antigen, and are negative for cytokeratins, EMA, HMB45 and HHV-8.2,3 While the differential diagnosis for any vascular lesion of the kidney will include angiosarcoma, the latter will usually display clear-cut malignant features, including clearly infiltrative growth, high cellularity, cytological atypia, spindling of cells, mitotic activity and necrosis, along with a clinically aggressive course.1 Unusual richly vascularised variants of RCC and angiomyolipoma may also need to be considered

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and excluded with the aid of immunohistochemistry. Careful attention to the characteristic constellation of morphological features of anastomosing haemangioma will exclude a range of other benign vascular lesions, all of which are rare in the kidney. The ultrasound appearance of renal haemangioma is similar to its counterpart in the liver, which is a more common visceral location for this type of tumour and includes echogenic texture.4 On contrast enhanced CT imaging it appears as a well demarcated, heterogeneous, solid and usually nonenhancing lesion,3,4 similar to RCC and other malignancies. Angiographic appearance is variable and of little use diagnostically.4 This radiological overlap in appearance contributes to the under-recognition of haemangioma pre-operatively and usual treatment with nephrectomy, total or partial. Recognition of a predominantly perirenal, pelvic and/or vascular tumour on imaging or at operation may allow more conservative surgical treatment7 or even selective embolisation,10 but this is very uncommon. Haemangiomas are often hilar in location, involving pelvic mucosa, pyramids or renal sinus.1,5,11 They sometimes arise within the cortex, especially in the context of end-stage kidney disease1 and are occasionally perirenal, including within the renal capsule.12 They show a propensity for involvement of large veins, including the inferior vena cava.6,5,9 Recurrences or metastases have not been described, although limited follow-up is available for many of these recently recognised lesions (Brown et al. 9 cases, median 44 months;1 Kryvenko et al. 5 cases, 27 months;3 Montgomery2 3 cases, median 12 months follow-up). Our patient, who had a number of comorbidities, died as a result of complications following surgery and not from malignant behaviour of the tumour. Conservative management is an option for the management of these benign lesions, provided it is recognised. However, radiological investigations (CT in particular) cannot reliably distinguish this vascular tumour from RCC and therefore surgical intervention is usually the preferred management. In summary, we present a case of a rare and recently recognised benign vascular tumour of the kidney, termed ‘anastomosing haemangioma’, and one of the largest reported to date. This lesion has characteristic morphology, which should be distinguished from angiosarcoma, given its apparently benign course. The potential for conservative management is limited by its propensity to present as a malignant-appearing solid mass on imaging or as an incidental finding at nephrectomy, but should be considered in the case of a minimally contrastenhancing solid lesion at the hilum or capsular region. Conflicts of interest and sources of funding: The authors state that there are no conflicts of interest to disclose. David R. Wetherell* Alison Skene{ Kiran Manya* Rustom P. Manecksha* Yee Chan* Damien M. Bolton* Departments of *Urology, and {Anatomical Pathology, Austin Hospital, Heidelberg, Vic, Australia Contact Dr D. Wetherell. E-mail: [email protected]

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1. Brown JG, Folpe AL, Rao P, et al. Primary vascular tumors and tumor-like lesions of the kidney: A clinicopathologic analysis of 25 cases. Am J Surg Pathol 2010; 34: 942–9. 2. Montgomery E, Epstein JI. Anastomosing hemangioma of the genitourinary tract: A lesion mimicking angiosarcoma. Am J Surg Pathol 2009; 33: 1364–9. 3. Kryvenko ON, Gupta NS, Meier FA, et al. Anastomosing hemangioma of the genitourinary system: Eight cases in the kidney and ovary with immunohistochemical and ultrastructural analysis. Am J Clin Pathol 2011; 136: 450–7. 4. Lee HS, Koh BH, Kim JW, et al. Radiologic findings of renal hemangioma: report of three cases. Korean J Radiol 2000; 1: 60–3. 5. Bhayani SB, Humphrey PA, Kibel AS. Renal sinus haemangioma with inferior vena cava involvement. BJU Int 2003; 92 (Suppl 3): e53. 6. Hull Iii GW, Genega EM, Sogani PC. Intravascular capillary hemangioma presenting as a solid renal mass. J Urol 1999; 162: 784–5. 7. Okuno T, Ando M, Arisawa C, et al. A case of perirenal hemangioma mimicking renal cell carcinoma. Int J Urol 1999; 6: 104–6. 8. Akkad T, Tsankov A, Pelzer A, et al. Early diagnosis and straightforward surgery of an asymptomatic primary angiosarcoma of the kidney led to long-term survival. Int J Urol 2006; 13: 1112–4. 9. Zhao X, Zhang J, Zhong Z, et al. Large renal cavernous hemangioma with renal vein thrombosis: case report and review of the literature. Urology 2009; 73: 443. 10. Lang EK, Atug F, Thomas R. Selective embolization of capillary hemangioma of the renal papilla. J Urol 2007; 177: 1146. 11. Jahn H, Nissen HM. Haemangioma of the urinary tract: review of the literature. Br J Urol 1991; 68: 113–7. 12. Wang T, Palazzo JP, Mitchell D, et al. Renal capsular hemangioma. J Urol 1993; 149: 1122–3.

DOI: 10.1097/PAT.0b013e32835c782b

Desmoplastic trichoepitheliomas with perineural involvement Sir, Desmoplastic trichoepithelioma (DTE) is a benign adnexal tumour showing follicular differentiation, which stereotypically presents on the cheek of young women.1 The most critical differential diagnoses include infiltrating/morphoeic basal cell carcinoma and microcystic adnexal carcinoma. When assessing this differential diagnosis, perineural invasion is generally considered to indicate malignancy.1 Recently, however, a small series and accompanying case report have suggested that perineural invasion can rarely be seen in otherwise typical DTE.2,3 We report two additional cases of this phenomenon and discuss the important clinical implications of accurate recognition of this somewhat counterintuitive finding.

A

Case 1 was a 22-year-old woman who presented to a plastic surgeon with a shallow, scar-like depression on her cheek which had been present for many months. The lesion was prone to surface crusting, which prompted her to seek medical attention. She thought that the lesion may have been growing slowly, but there was no pain associated with it. She had no history of other significant skin lesions and she was otherwise fit and healthy. Excisional biopsy was performed. In addition to haematoxylin and eosin stained sections, immunoperoxidase slides were prepared by standard techniques and included slides labelled with antibodies to cytokeratin 20 and dual labelled with cytokeratin AE1/AE3 and S100. Microscopic examination showed complete excision of a symmetrical and circumscribed tumour confined to the dermis, measuring 3.5
2 mm on the slides (Fig. 1A). There were strands of basaloid cells, with areas of keratin cyst formation superficially, set within a dense eosinophilic sclerotic (’desmoplastic’) stroma. Focal keratin granuloma formation was also present superficially. The constituent basaloid cells were cytologically bland, with uniform nuclei showing a fine chromatin pattern and small nucleoli (Fig. 1B). Neither mitotic figures nor apoptosis were identified and there was no evidence of tumour-stromal clefting or extracellular mucin. There was an immediately adjacent intradermal melanocytic naevus. CK20 immunohistochemical staining highlighted the presence of occasional Merkel cells within the tumour cords (Fig. 1B, inset). Notably, multiple foci at the deep periphery of the tumour showed growth of cords of tumour cells associated with small nerve twigs (Fig. 2A). The tumour cells in these areas showed partial circumferential growth around the nerve fibres, with a single focus showing complete envelopment. The involved nerve fibres measured between 0.03 and 0.05 mm in diameter. Combined S100 and AE1/AE3 immunohistochemical staining confirmed these findings (Fig. 2B). Case 2 was a 14-year-old girl who presented to her general practitioner with a well delineated slightly depressed plaque approximately 10 mm in diameter above the right eyebrow. It had been present for some months, without rapid enlargement and was somewhat paler than the surrounding skin, resembling a scar or collapsed epidermoid cyst. The patient had no similar lesions and no significant current or previous medical conditions. There was no family history of note. A 3 mm punch biopsy of the lesion was performed and showed cords and nests of bland, regular epithelial cells in a desmoplastic stroma confined to the dermis. There were

B

CK20

Fig. 1 (A) Low power view of the tumour seen in Case 1. The tumour was relatively well circumscribed, with the suggestion of a central dell on the skin surface (H&E). (B) High power view of the tumour seen in Case 1, showing cords of cytologically bland basaloid cells, set within a sclerotic background (H&E). Inset: CK20 immunohistochemical staining highlighted the presence of occasional Merkel cells within the tumour cords.

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A

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B

Fig. 2 (A) Focal perineural involvement around small nerve twigs was noted within the confines of the tumour in Case 1 (H&E). (B) This observation was confirmed with dual immunohistochemical staining for S100 (brown chromogen) and AE1/AE3 (red chromogen).

foci of keratinisation, rudimentary hair germ formation and calcification with inconspicuous mitotic activity. Multiple areas of perineural involvement of fine dermal nerves less than 0.1 mm diameter were seen within the lesion (Fig. 3). Small numbers of CK20 positive cells were present within the tumour cords with an identical pattern to that illustrated in Case 1. Five months later the lesion had slightly reduced in size and re-excision was under consideration. The differential diagnosis of a neoplasm showing thin cords of basaloid cells within the dermis traditionally includes benign possibilities such as syringoma and desmoplastic trichoepithelioma, with infiltrating basal cell carcinoma and microcystic adnexal carcinoma representing malignant considerations.1 Separation of syringoma and DTE is generally straightforward and of relatively limited clinical importance. In contrast, distinction between the benign and malignant entities is critical and occasionally problematic, particularly given the often cosmetically sensitive location. Furthermore, malignant lesions may need aggressive surgery with high rates of local recurrence if inadequately excised.1 A number of clinical, histopathological and immunohistochemical criteria have been proposed to distinguish DTE from malignant mimics.1,4,5 DTE typically presents as a firm stable plaque which may have an annular appearance on the face, including the cheek, forehead, chin and nose. Up to one-third occur in patients under 30 years of age.4 In contrast, infiltrating/morphoeic basal cell carcinoma and microcystic adnexal carcinoma generally lack an annular morphology and present as progressive lesions, often in older patients with a more widespread distribution on the head and neck region. If present, ulceration is suggestive of a malignant diagnosis.4–6

A

Several histological studies have addressed the distinction of desmoplastic trichoepithelioma from infiltrating basal cell carcinoma.4,5,7 Histologically, DTE is typically a symmetrical and circumscribed lesion, limited to the dermis and often showing a central dell. The growth pattern is characterised by thin, branching cords of cells with frequent formation of keratin horn cysts. There is often calcification and keratin granuloma formation associated with horn cyst rupture. Some authors have attached importance to the presence of a cuff of thickened collagen around the cords of cells.6 The presence of a co-existing melanocytic naevus is common, being reported in up to 15% of cases.1 We believe that the cases presented essentially fulfill all of the criteria for distinction of DTE from malignant alternatives, with the exception of perineural involvement. Small numbers of CK20 positive Merkel cells within the cords of neoplastic cells in both cases further support follicular germinative differentiation.8 Although we had previously considered perineural invasion to be indicative of malignancy in this context, our findings closely correspond to those described in recent reports by Jedrych et al. and McCalmont et al.2,3 These authors describe eight typical DTEs which showed perineural involvement of small dermal nerves, either within the tumour or at its periphery. This limited perineural involvement is in contrast to that seen in malignant mimics, particularly microcystic adnexal carcinoma, where involvement of larger nerves and spread some distance from the main lesion are common.1 Although very limited follow-up data are available, no recurrence or other adverse outcome have been reported to date. There have been a number of critiques of the use of the term ‘invasion’ in dermatopathology.9 Given that the term

B

Fig. 3 (A) Medium power view of the tumour seen in Case 2. Again, it has appearances typical of a desmoplastic trichoepithelioma, with cords of basaloid cells and occasional keratin microcysts in a sclerotic background (H&E). (B) Focal perineural involvement was also noted in this case (H&E).

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is entrenched in the clinical and pathological lexicon and considered synonymous with malignancy by many clinicians, we prefer to use alternative terminology ‘perineural involvement’ to describe this phenomenon. It remains speculative as to whether this perineural process represents a morphological mimic of perineural invasion, analogous to that reported in a range of non-neoplastic processes in the skin and other organs,10 a manifestation of an epithelial-neural interaction (e.g., mediated by p75),3 or an epithelial-neural crest interaction which more commonly manifests as an associated melanocytic naevus. Whatever the mechanism, awareness that perineural involvement can occur in DTE is critical for pathologists. Correct diagnosis is likely to be particularly demanding on a punch or other partial biopsy. In the absence of long-term follow-up data, we believe that perineural involvement in a putative DTE on partial biopsy should be an indication for conservative complete excision. While perineural involvement remains an important factor in suggesting the possibility of carcinoma, we believe that it does not necessarily mandate a malignant diagnosis. Acknowledgements: The authors would like to acknowledge Dr L. Yu (Dermatopathology WA) for reviewing Case 1 and Drs Ross Anderson and Fiona Kingston for the information and material they supplied for Case 2. Conflicts of interest and sources of funding: The authors state that there are no conflicts of interest to disclose. Nathan Tobias Harvey* Tamazin Leecy* Trevor W. Beer{ Benjamin Andrew Wood* *Department of Anatomical Pathology, PathWest, QEII Medical Centre, Nedlands, and School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, and {Cutaneous Pathology, Nedlands, WA, Australia Contact Benjamin A. Wood. E-mail: [email protected] 1. Kazakhov DV, Michal M, Kacerovska D, McKee PH. Cutaneous Adnexal Tumours. Philadelphia: Lippincott Williams and Wilkins, 2012. 2. Jedrych J, Leffell D, McNiff JM. Desmoplastic trichoepithelioma with perineural involvement: a series of seven cases. J Cutan Pathol 2012; 39: 317–23. 3. McCalmont TH, Humberson C. Neurotropism in association with desmoplastic trichoepithelioma. J Cutan Pathol 2012; 39: 312–3. 4. Brownstein MH, Shapiro L. Desmoplastic trichoepithelioma. Cancer 1977; 40: 2979–86. 5. Costache M, Bresch M, Boer A. Desmoplastic trichoepithelioma versus morphoeic basal cell carcinoma: a critical reappraisal of histomorphological and immunohistochemical criteria for differentiation. Histopathology 2008; 52: 865–76. 6. Ackerman AB, Boer A. Histopathologic Diagnosis of Adnexal Epithelial Neoplasms. New York: Ardor Scribendi, 2008. 7. Takei Y. Criteria for histologic differentiation of desmoplastic trichoepithelioma from morphea-like basal cell carcinoma. Am J Dermatopathol 1985; 7: 207–21. 8. Abesemis-Cubillan E, El-Shabrawi-Caelen L, LeBoit PE. Merkel cells and sclerosing epithelial neoplasms. Am J Dermatopathol 2000; 22: 311–5. 9. Weyers W. The fallacy of the concept of invasion—Critique in historical perspective with implications for diagnosis of early malignant neoplasms. Am J Dermatopathol 2012; 34: 91–102. 10. Dunn M, Morgan MB, Beer TW, et al. Histologic mimics of perineural invasion. J Cutan Pathol 2009; 36: 937–42.

DOI: 10.1097/PAT.0b013e32835c7703

Pathology (2013), 45(2), February

Neutrophilic dermatosis of the dorsal hands: an often under recognised and mistreated entity

Sir, Neutrophilic dermatosis (pustular vasculitis) of the dorsal hands (NDDH) is an uncommon disorder which may be initially misdiagnosed as an infectious process, leading to inappropriate antibiotic treatment, surgical debridement and even amputation. Clinical and pathological recognition and subsequent treatment with corticosteroids can prevent serious adverse outcomes. We describe the case of a woman initially thought to have cellulitis and managed unsuccessfully with antibiotics, until dermatological review and biopsy led to the diagnosis of NDDH. An 87-year-old woman from a nursing home presented to the emergency department with a 3 week history of swelling and erythema of the dorsum of the left hand, with ulceration developing in the fourth week. She had been treated with two courses of antibiotics with no response. There was some question of a prior insect bite. No other lesions were present. She had a history of gastric adenocarcinoma, treated by gastrectomy 5 years previously, chronic obstructive pulmonary disease, Crohn’s disease, osteoarthritis and osteoporosis. She was taking a large number of medications, none of which had recently been altered. On examination she was afebrile. On the dorsum of the left hand she was found to have an erythematous fluctuant area, with intact skin in the centre and peripheral ulceration (Fig. 1). No abnormalities were present on plain film imaging of the hand. Her white cell count (WCC) was normal and her C-reactive protein (CRP) was mildly elevated (CRP 23). Plastic surgical review supported a diagnosis of cellulitis and intravenous antibiotic treatment was commenced. Despite this management, the lesion progressed over the following 2 days, with further ulceration developing. At this stage dermatological opinion was sought. A clinical diagnosis of NDDH was suggested and biopsy material was taken for histological and microbiological study. Histology of the biopsy showed a dense neutrophilic dermal infiltrate associated with leucocytoclastic debris and scattered admixed eosinophils. Within the area of dermal neutrophlic inflammation, fibrinoid necrosis of small vessel walls was seen. The inflammatory changes were confined to the upper and mid dermis. The vessels away from the area of inflammation did

Fig. 1 Clinical photo of the lesion with progression to ulceration after treatment with antibiotics.

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not show evidence of vasculitis (Fig. 2). No organisms were identified on haematoxylin and eosin (H&E) or special stains. Microbiological culture was negative. The clinical and pathological features were considered to be consistent with NDDH. Antibiotics were ceased and the patient was treated with prednisolone. On review 3 weeks later, the lesion had completely healed without scarring. In 1995 Strutton et al. described six patients with lesions clinically resembling Sweet’s syndrome, but localised to the dorsum of the hands and showing a definite leukocytoclastic vasculitis.1 This condition was termed ‘pustular vasculitis of the dorsum of the hands’. In 2000, Galaria et al. described three clinically and histologically similar cases without systemic symptoms and lacking a true vasculitis, leading the authors to propose the terminology ‘neutrophilic dermatosis of the dorsal hands’.2 In the largest series to date, DiCaudo and Connolly described seven cases.3 All patients were female and presented with severely painful pustular nodules and plaques, frequently accompanied by ulceration and involving the dorsal hands. Fever was reported in three patients and a peripheral neutrophilia in two cases. Five of the six patients also had evidence of lesions at other sites, although these were described as minimal. Cutaneous lesions resolved in six of seven patients after treatment with steroids, dapsone or minocycline hydrochloride. Additional case reports have emerged in subsequent years, with patients showing peripheral neutrophilia, increased erythrocyte sedimentation rate (ESR), CRP and abnormal liver function tests. Association with infection (pharyngitis), bowel disorders, malignancy and Reynaud’s phenomenon have been reported.3–8

Fig. 2 (A) Low power view showing dense dermal neutrophilic infiltrate (H&E). (B) High power view showing small vessel vasculitis (H&E).

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Clinically the lesions are localised to the dorsum of the hands and usually present as pustular nodules (sometimes with haemorrhage), or boggy red plaques, often with ulceration. Despite frequent ulceration and recurrence in some cases, the lesions resolve without scarring with appropriate treatment. Histopathologically, NDDH shows a dense dermal infiltrate of neutrophils, sometimes associated with subepidermal oedema. Abundant leukocytoclastic debris, both extracellular and within macrophages is usually seen. Variable numbers of eosinophils and lymphocytes may also be present. Although the original description included fibrinoid necrosis of small vessels, usually within the area of inflammation, it should be noted that some subsequently reported cases do not show evidence of vasculitis, making them histologically identical to Sweet’s syndrome.7 Variable epidermal changes may occur, including spongiosis, ulceration, neutrophilic infiltration or neutrophilic microabscesses. Definitionally, there should be no evidence of a primary infectious aetiology, either on special stains or microbiological culture. When infectious causes have been excluded, the histological differential diagnosis includes other neutrophilic dermatoses such as Sweet’s syndrome, pyoderma gangrenosum, pustular drug reactions, rheumatoid neutrophilic dermatosis, bowel associated dermatosis arthritis syndrome and early phases of erythema elevatum diutinum. The overlap between Sweet’s syndrome, rheumatoid neutrophilic dermatosis, bowel associated dermatosis arthritis syndrome and NDDH remains unclear. A minimalist perspective would consider the latter conditions simply variants of Sweet’s syndrome in which the clinical presentation and disease association are stereotypical. While accepting the likelihood that these ‘entities’ are in fact closely related and acknowledging that the appropriate management is similar, we consider the stereotypical clinical features including the distinct localisation, frequent presence of ulceration and reported variable presence of vasculitic changes significant enough to warrant identification of NDDH as a separate entity. The patient we present had a medical history including malignancy and Crohn’s disease, both of which are reported as associations in this range of steroid responsive neutrophilic dermatoses, although it is not clear that any of them were aetiologically involved. While a number of series have identified a range of disease associations with Sweet’s syndrome, there is a need for larger case series to investigate the clinical disease associations of NDDH and its relationship, if any, to these other conditions. The principal differential diagnostic consideration when faced with an ulcerated suppurative dermatitis is that of infection. In all such cases, careful examination of the tissue by routine and special stains, as well as microbiological culture is critical. Pathologists should also be cognisant of any prior antibiotic therapy and the clinical response to this therapy. If an infectious aetiology cannot be identified, the possibility of a primary immunologically mediated suppurative inflammatory process should be considered. This is particularly critical, as antibiotic therapy is ineffective in the management of such conditions and in many cases surgical debridement is counterproductive. In contrast, there is typically a strikingly rapid response of NDDH to medical management with corticosteroids and dapsone, with less convincing results for minocycline therapy being reported.2,3 Awareness of the clinical and histopathological features of NDDH is requisite for pathologists to consider this possibility and separate it from infectious processes. Furthermore, pathological recognition may be of significant benefit in managing

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patients, whereas descriptive reports of ulceration and inflammatory changes are unlikely to lead clinicians unaware of this condition to institute appropriate management. Conflicts of interest and sources of funding: The authors state that there are no conflicts of interest to disclose. Tamazin Leecy* Austen Anderson{ Jamie Von Nida{ Nathan Harvey* Benjamin Wood* *Pathwest, QEII Site, and {Sir Charles Gairdner Hospital, Nedlands, WA, Australia Contact Dr T. Leecy. E-mail: [email protected] 1. Strutton G, Weedon D, Robertson I. Pustular vasculitis of the hands. J Am Acad Dermatol 1995; 32: 192–8. 2. Galaria NA, Junkins-Hopkins JM, Kligman D, James WD. Neutrophilic dermatosis of the dorsal hands: pustular vascultis revisited. J Am Acad Dermatol 2000; 43: 870–4. 3. DiCaudo DJ, Connolly SM. Neutrophilic dermatosis (pustular vasculitis) of the dorsal hands. A report of 7 cases and a review of the literature. Arch Dermatology 2002; 138: 361–5. 4. McNeely MC, Jorizzo JL, Solomon AR, Schmalsteig FC, Cavallo T. Primary idiopathic cutaneous pustular vasculitis. J Am Acad Dermatol 1986; 14: 939–44. 5. Hall AP, Goudge RJ, Ireton HJ, Burrell LM. Pustular vasculitis of the hands. Australas J Dermatol 1999; 40: 204–7. 6. Curco N, Pagerols X, Tarroch X, Vives P. Pustular vasculitis of the hands, report of two men. Dermatology 1998; 196: 346–7. 7. Weedon D. Weedon’s Skin Pathology. 3rd ed. Philadelphia: Churchill Livingstone, 2010; Chapter 8, The vasculopathic pattern. 8. Koulaouzidis A, Campbell S, Bharati A, Leonard N, Azurdia R. Primary biliary cirrhosis associated pustular vasculitis. Ann Hepatol 2006; 5: 177–8.

DOI: 10.1097/PAT.0b013e32835cc1fa

Metastasis of basal cell carcinoma in a patient with basal cell carcinoma syndrome Sir, Nevoid basal cell carcinoma syndrome (NBCCS) is a rare autosomal dominant condition with high penetrance and Table 1

Pathology (2013), 45(2), February

variable expressivity. It is estimated that NBCCS has a prevalence of between 1 in 57 000 to 1 in 256 000 across different global populations.1–3 NBCCS affects males and females equally. The clinical features (Table 1) of the syndrome usually arise in the first, second and third decades.4,5 The genetic abnormality associated with NBCCS is a mutation of the PTCH gene on chromosome 9q (22.3-q31).6 This gene functions as a tumour suppressor through its interaction with other components of the Hedgehog signalling pathway.7 Herein, we present a case of metastatic basal cell carcinoma to vertebra and axillary lymph node in a patient with NBCCS. The patient was a 51-year-old Caucasian male with a long clinical history of NBCCS based on: multiple histologically proven basal cell carcinomas (BCCs; the first of which appeared in his twenties), a childhood history of multiple maxillofacial procedures for mandibular cysts, bifid ribs, calcification of the falx cerebri and palmar pits. He had no known family history of NBCCS and had never received radiotherapy. At our institution, he had 33 BCCs surgically excised since December 2006. Only one of these lesions, from the central upper back, had an involved surgical margin. Wider excision showed no residual tumour. This BCC from the central upper back showed no squamous differentiation. There was a single focus of perineural invasion, involving a nerve of 0.16 mm diameter, which was >15 mm from the deep margin. No other BCC showed perineural invasion and there was no lymphovascular invasion in any of the excisions. The patient presented to his general practitioner in 2009 with a history of interscapular back pain radiating across the right back, worsening over several months and requiring increasing doses of oral analgesics. The pain corresponded to a dermatomal distribution of the fourth thoracic vertebra (T4). On examination, multiple small pearly translucent nodules with overlying telangiectatic blood vessels consistent with BCCs were evident over the patient’s neck, chest, back and upper arms. There were multiple scars from previous excisions. Palpable lymphadenopathy was identified in the right axilla. Imaging demonstrated a destructive bony lesion of T3 suspicious for neoplastic disease (Fig. 1A). A technetium bone scan demonstrated increased uptake in the thoracic vertebra, in the anterior left fifth rib and in several pulmonary nodules. There was no radiological evidence of

The diagnostic criteria of nevoid basal cell carcinoma syndromes

Diagnosis requires the presence of two major, or one major and two minor criteria: Major criteria 1. More than two BCCs or one under the age of 20 years. 2. Histologically proven odontogenic keratocysts of the jaw. 3. Three or more cutaneous palmar or plantar pits. 4. Bifid, fused or markedly splayed ribs. 5. First degree relative with NBCCS. Minor criteria 1. Macrocephaly. 2. The presence of one of the following orofacial congenital malformations: cleft lip or palate, frontal bossing, ‘coarse face’, moderate or severe hypertelomerism. 3. The presence of one of the following skeletal abnormalities: Sprengel deformity, marked pectus deformity, marked syndactyly of the digits. 4. Radiological abnormalities: bridging of the sella turcica, vertebral anomalies such as hemivertebrae, fusion or elongation of the vertebral bodies, modelling defects of the hands and feet, or flame-shaped lucencies of the hands or feet. 5. Ovarian fibroma. 6. Medulloblastoma.

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Fig. 1 (A) T2-weighted sagital MRI image demonstrating a destructive lesion in the vertebral body of T3. (B) Core biopsy specimen from the right axillary nodes (H&E).

an overlying contiguous tumour on either computed tomography (CT) or magnetic resonance imaging (MRI), nor was there any suggestion of another primary tumour on imaging obtained through the chest, abdomen and pelvis. Fine needle aspirate (FNA) was performed on the palpable right axillary lymph nodes and showed a few scattered cohesive groups of tumour cells with a high nuclear to cytoplasmic ratio, within a background of necrotic and somewhat mucinous material. The diagnosis was malignant tumour, favouring non-small

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cell carcinoma. A core biopsy was performed on the same nodes in June 2010 and showed fibroadipose tissue infiltrated by basal cell carcinoma, with focal squamous differentiation (Fig. 1B). The patient underwent a decompression and corpectomy with posterior instrumentation at the level of T3. At surgery, there was no suggestion of contiguity with an overlying tumour. The specimen was sent for histological evaluation. Microscopy showed bone and connective tissue infiltrated by malignant tumour with features typical of basal cell carcinoma. The tumour comprised sheets, nests and trabeculae of cohesive basaloid tumour cells with high nuclear to cytoplasmic ratio and hyperchromatic, clumped chromatin (Fig. 2A). There was only very focal perineural invasion (Fig. 2B) and involvement of a ganglion within soft tissue. Focal squamous differentiation was identified, representing <1% of the tumour (Fig. 2C). Immunohistochemistry showed the tumour to be positive for bcl-2, CK5/6 and p63 with patchy positivity for Ber-EP4 and EMA. CK20 was negative. A blood sample was sent to Yale University to undergo formal testing for a mutation in the PTCH gene using linkage analysis. This test was unable to demonstrate a mutation. Whilst the clinical diagnosis of Gorlin’s syndrome is not in doubt, (the patient has at least four of the major criteria of this syndrome), the formal genetic testing was unable to show a mutation in the PTCH gene. This particular genetic test uses polymerase chain reaction (PCR) amplification to multiply the 23 coding region exons of the PTCH gene together with the flanking regions which contain intron-exon junctions.8 The laboratory quotes a sensitivity of between 80% and 85% in ‘typical patients’ (i.e., patients displaying at least two major criteria). This false negative result suggests ‘additional rearrangements or mutations in alternate splice forms’,8 or alternatively, an as yet unelucidated mutation in the regulatory elements, downstream messengers or other components of the Hedgehog signalling pathway. The mutation in this particular patient may be better understood as more information about the mutational spectrum becomes available and testing methodologies are updated.8 Basal cell carcinomas are regarded as potentially locally aggressive and invasive cutaneous tumours which metastasise only rarely (as infrequently as 1 in 35 000).9,10 To our knowledge, there are just over 300 case reports of metastatic basal cell carcinoma in the literature9 and this represents only the third case reported in association with NBCCS.11 Aggressive BCC behaviour in patients with NBCCS has been associated with the use of radiotherapy as initial treatment for lesions and therefore is contraindicated.12 Vismodegib, a novel oral inhibitor of the Hedgehog signalling pathway,

Fig. 2 (A) Vertebral specimen demonstrating BCC morphology, (B) focal perineural invasion, and (C) focal squamous differentiation (H&E).

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is currently undergoing clinical trials for the treatment of locally advanced and metastatic BCC not amenable to surgery or radiotherapy, and may offer an effective therapeutic option in the near future.13 This case demonstrates that high-risk tumour characteristics, including divergent squamous differentiation, deep extension and perineural invasion, should alert the clinician to the increased risk of aggressive behaviour and that bone appears to be a preferential site for metastasis based on the rare literature. Acknowledgements: The authors would like to thank Dr George Tsikleas and Dr Irene Krajewska of Sullivan Nicolaides Pathology, for providing the axillary lymph node FNA and core biopsy slides. Conflicts of interest and sources of funding: The authors state that there are no conflicts of interest to disclose. Nicholas C. Stewart* Blake O’Brien{ Leo Francis{ David Graham{ Steven Yang{ *Royal Prince Alfred Hospital, Camperdown, NSW, and {Royal Brisbane and Women’s Hospital, Brisbane, Qld, Australia Contact Dr N. C. Stewart. E-mail: [email protected] 1. Farndon PA, Del Mastro RG, Evans DG, et al. Location of gene for Gorlin’s syndrome. Lancet 1992; 339: 581–2. 2. Pratt MD, Jackson R. Nevoid basal cell carcinoma syndrome. A 15-year follow-up of cases in Ottawa and the Ottawa Valley. J Am Acad Dermatol 1987; 16: 964–70. 3. Shanley S, Ratcliffe J, Hockey A, et al. Nevoid basal cell carcinoma syndrome: review of 118 affected individuals. Am J Med Genet 1994; 50: 282–90. 4. Kimonis VE, Goldstein AM, Pastakia B, et al. Clinical manifestations in 105 persons with nevoid basal cell carcinoma syndrome. Am J Med Genet 1997; 69: 299–308. 5. Ortega Garcia de Amezaga A, Garcia Aregui O, Zepeda Nuno S, et al. Gorlin-Goltz syndrome: clinicopathologic aspects. Med Oral Patol Oral Cir Bucal 2008; 13: E338–43. 6. Cohen MMJ. Nevoid basal cell carcinoma syndrome: molecular biology and new hypotheses. Int J Oral Maxillofac Surg 1999; 28: 216–23. 7. Johnson RL, Rothman AL, Xie J, et al. Human homolog of patched, a candidate gene for the basal cell nevus syndrome. Science 1996; 272: 1668–71. 8. Klein RD, Dykas DJ, Daniel JAS, et al. Clinical testing for the nevoid basal cell carcinoma syndrome in a DNA diagnostic laboratory. Genet Med 2005; 7: 611–9. 9. Aldhaban S, Marc S, Eshki M, et al. Giant basal cell carcinoma with regional lymph node and distant lung metastasis. Eur J Dermatol 2011; 21: 972–5. 10. Von Domarus H, Stevens PJ. Metastatic basal cell carcinoma. Report of five cases and review of 170 cases in the literature. J Am Acad Dermatol 1984; 10: 1046–60. 11. Lamon T, Gerard S, Meyer N, et al. Exceptional bone metastasis of basal cell carcinoma in Gorlin-Goltz syndrome. Dermatology 2010; 220: 57–9. 12. Southwick GJ, Schwartz RA. The basal cell nevus syndrome: disasters occurring among a series of 36 patients. Cancer 1979; 44: 2294–305. 13. Cirrone F, Harris CF. Vismodegib and the hedgehog pathway: A new treatment for basal cell carcinoma. Clin Ther 2012; 34: 2039–50.

DOI: 10.1097/PAT.0b013e32835cc2bc

Pathology (2013), 45(2), February

Further evidence that the IS481 target is suitable for real-time PCR detection of Bordetella pertussis

Sir, Conventional and real-time polymerase chain reaction (PCR) is a routine diagnostic method to detect Bordetella pertussis in clinical samples due to its high sensitivity and rapid turnaround. Of the described assays, many target the insertion sequence IS481.1 However, there is a concern that B. pertussis assays targeting IS481 may produce false positive diagnostic results due to cross reaction with B. holmesii DNA.2 Like B. pertussis, B. holmesii contains IS481 elements3 and can be detected in nasopharyngeal aspirates from patients with pertussis-like illness.4 However, questions remain over whether this potential for cross-reaction is such that the IS481 target should not be used at all for B. pertussis testing. In this study, we used real-time PCR to retrospectively investigate the prevalence of B. holmesii in nucleic acids extracted from respiratory samples of patients with respiratory illness. Two cohorts were investigated. Cohort 1 comprised 396 samples (250 nasopharyngeal aspirates, 113 swabs and 33 other) from patients submitted for B. pertussis PCR in Queensland, Australia, and collected during the years 2001, 2002, 2008 and 2011 (summarised in Table 1). Cohort 2 comprised a convenience sample of 660 samples (predominantly nasopharyngeal aspirates; n ¼ 547) from patients (54.8% male) with acute respiratory tract illness in Queensland Australia collected during 2008; these 660 samples had been submitted for respiratory virus testing but not for B. pertussis investigation. Subjects ranged in age from 8 days to 92.4 years (mean 16.6 years). Samples from 2001 to 2002 had been extracted using the High Pure Viral Nucleic Acid kit (Roche Diagnostics, Australia) whereas the later samples were extracted using the Qiagen DX Xtraction kit on the Qiagen X-tractor Gene instrument (Qiagen, Australia). All extracts had been stored at –708C prior to testing. The B. holmesii real-time PCR targeted the recA gene. Primer and probe sequences were previously described.2 The real-time PCR reaction consisted of 4 pmoles of probe (GeneWorks, Australia), 10 pmoles each of sense and antisense primer (Geneworks, Australia), 1x Qiagen QuantiTect Probe PCR Master Mix (Qiagen, Australia), and 5 mL of template in a final reaction volume of 25 mL. Amplification was carried out on a Rotor-Gene Q instrument (Qiagen, Australia) at 958C for 15 min, followed by 45 cycles of 958C for 15 s and 608C for 60 s. Overall, using the recA PCR assay we did not detect the presence of B. holmesii DNA in any of the 1056 tested clinical extracts, including 53 samples that were positive by the B. pertussis IS481 PCR. One limitation of this study was that only 53 B. pertussis IS481 PCR positive samples were investigated, and so it could be argued that our study was not sufficiently powered to detect B. holmesii given that it only accounts for a small percentage of pertussis syndrome. However, the potential for cross reaction between these two species of Bordetella has been evaluated by several studies, some of which recommend use of additional or alternate targets to IS481.2,5–7 Antila et al. screened Finnish and Dutch patients with pertussis-like symptoms using realtime PCR to determine whether the presence of B. holmesii confounds IS481 real-time and conventional PCR and to

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Table 1

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Summary of clinical specimens for Cohort 1

Cohort Sample size, n (% male) Age range, years (mean) Specimen type B. pertussis positive (%) B. holmesii positive

Jan 2001–Jan 2002

Jan 2008–Dec 2008

Mar 2011–May 2011

125 (44.8) 0–75 (7.7) 104 NPA, 3 endotracheal aspirates, 6 swabs, 5 other, 7 unspecified 27 (21.6) 0

61 (47.5) 0.03–74 (7.2) 58 NPA, 3 swabs

210 (50.0) 0–80 (22.7) 88 NPA, 104 swabs, 15 other, 1 unspecified 19 (9.1) 0

7 (11.5) 0

NPA, nasopharyngeal aspirate.

establish the prevalence of B. holmesii in the clinical setting.5 Whilst 2315 (20.5%) of the samples analysed were positive for the IS481 target, no evidence of B. holmesii DNA was found. Findings suggested B. holmesii was not among the causative agents of pertussis-like symptoms and does not confound IS481 detection of B. pertussis. A similar study by Guthrie et al. assessed the false positive rate of the IS481 real-time PCR in Ontario, Canada. Using the IS481 target, 16.6% (1707) of a total 10 254 nasopharyngeal swabs from patients with pertussis-like illness were positive.2 Further screening using the recA target detected B. holmesii DNA in only 12 of 1707 (0.7%) positive B. pertussis samples. Thus, our Australian data simply add further weight to a growing body of evidence that B. holmesii is rarely detected in these samples. Despite evidence of the potential for cross reaction, consideration must also to be given to the sensitivity of B. pertussis targets, in addition to their specificity. We have found the IS481 to have a lower detection limit than other B. pertussis targets including BP283 and BP485 assays (data not shown) and this is consistent with other studies.1,6,8 Overall, ours and other studies show that potential for cross-reaction is limited at best and given the higher sensitivity of the IS481 target it is our opinion that a shift away from this target is not justified, and in fact may be counterproductive. Nonetheless, clinical laboratories using the IS481 target could otherwise consider adding an appropriate comment to B. pertussis PCR reports indicating the potential for cross-reaction with B. holmesii, an infrequent cause of pertussis syndrome in humans. Conflicts of interest and sources of funding: The authors state that there are no conflicts of interest to disclose. Hannah C. Cox*{ Kevin Jacob*{ David M. Whiley*{ Cheryl Bletchly{ Graeme R. Nimmo{§ Michael D. Nissen*{{ Theo P. Sloots*{{ *Queensland Paediatric Infectious Diseases Laboratory, Queensland Children’s Medical Research Institute, Children’s Health Service District, Queensland, {Clinical Medical Virology Centre, Sir Albert Sakzewski Virus Research Centre, University of Queensland, zMicrobiology Division, Pathology Queensland Central Laboratory, Royal Brisbane and Women’s Hospital Campus, and §Griffith University, Gold Coast, Qld, Australia Contact Dr T. P. Sloots. E-mail: [email protected]

1. Kosters K, Riffelmann IM, Von Konig CHW. Evaluation of a real-time PCR assay for detection of Bordetella pertussis and B. parapertussis in clinical samples. J Med Microbiol 2001; 50: 436–40. 2. Guthrie JL, Robertson AV, Tang P, Jamieson F, Drews SJ. Novel duplex real-time PCR assay detects Bordetella holmesii in specimens from patients with pertussis-like symptoms in Ontario, Canada. J Clin Microbiol 2010; 48: 1435–7. 3. Reischl U, Lehn N, Sanden GN, Loeffelholz MJ. Real-time PCR assay targeting IS481 of Bordetella pertussis and molecular basis for detecting Bordetella holmesii. J Clin Microbiol 2001; 39: 1963–6. 4. Mazengia E, Silva EA, Peppe JA, Timperi R, George H. Recovery of Bordetella holmesii from patients with pertussis-like symptoms: use of pulsed-field gel electrophoresis to characterize circulating strains. J Clin Microbiol 2000; 38: 2330–3. 5. Antila M, He Q, de Jong C, et al. Bordetella holmesii DNA is not detected in nasopharyngeal swabs from Finnish and Dutch patients with suspected pertussis. J Med Microbiol 2006; 55: 1043–51. 6. Probert WS, Ely J, Schrader K, et al. Identification and evaluation of new target sequences for specific detection of Bordetella pertussis by real-time PCR. J Clin Microbiol 2008; 46: 3228–31. 7. Roorda L, Buitenwerf J, Ossewaarde J, van der Zee A. A real-time PCR assay with improved specificity for detection and discrimination of all clinically relevant Bordetella species by the presence and distribution of three insertion sequence elements. BMC Res Notes 2011; 4: 11. 8. Knorr L, Fox J, Tilley P, Ahmed-Bentley J. Evaluation of real-time PCR for diagnosis of Bordetella pertussis infection. BMC Infect Dis 2006; 6: 62.

DOI: 10.1097/PAT.0b013e32835cc2d7

Tetraploidy with double t(15;17)(q22;q21) in acute promyelocytic leukaemia Sir, Acute promyelocytic leukaemia (APML) is a subtype of acute myeloid leukaemia characterised by the chromosomal translocation t(15;17)(q22;q21) with the PML-RARa fusion gene. Additional chromosomal abnormalities are occasionally found in patients with acute promyelocytic leukaemia. In this report, we describe of tetraploidy with two copies of the t(15;17)(q22;q21) in a patient with acute promyelocytic leukaemia which is an extremely rare occurrence. A 32-year-old Caucasian male patient presented with 2 week duration of gum bleeds and multiple large bruises all over the body. At presentation, his blood counts showed haemoglobin of 101 g/L, white cell count of 3.7
109/L, neutrophil count of 0.7
109/L and platelet count of 31 x109/L with 50% blasts in the blood film. A picture of disseminated intravascular coagulation was noted with prolonged prothrombin time (PT), prolonged activated partial thromboplastin time (APTT), low fibrinogen levels and very high D-dimer levels. The bone marrow biopsy demonstrated marked hypercellularity with 70% blasts and 18% abnormal large promyelocytes. The majority of blasts were unusually very large with cleaved,

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Pathology (2013), 45(2), February

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(RT-PCR) test of the bone marrow sample was also positive for PML-RARa transcripts with bcr 3 breakpoint. PML-RARa transcripts were quantified at 85.75% (PML-RARAa: ABL%) using the Ipsogen Cancer Profiler FusionQuant kit (Ipsogen, France). The patient received all-trans retinoic acid (ATRA) and chemotherapy for remission induction along with aggressive support with blood products. Coagulopathy recovered after 1 week and blood counts were normal after 4 weeks of initiation of therapy. Repeat bone marrow biopsy during that stage demonstrated complete morphological remission with less than 1% blasts and no evidence of the abnormal population in the immunophenotyping. Cytogenetics on the remission marrow showed a normal karyotype (46,XY) with no evidence of the abnormal clone seen at diagnosis. PML-RARa fusion transcript was also negative in RT-PCR test on the bone marrow sample. Additional chromosomal abnormalities were observed in 28% of 495 acute promyelocytic leukaemia patients studied in two consecutive PETHEMA trials (LPA96 and LPA99).1 Trisomy 8 was the most frequent additional chromosomal abnormality (36%), followed by abnormalities of 7q (5%). There were no cases of tetraploidy or near-tetraploidy observed in this study. In this study the patients with additional chromosomal abnormalities had higher incidence of coagulopathy ( p ¼ 0.03), lower platelet counts ( p ¼ 0.02) and higher relapserisk scores ( p ¼ 0.02) than those without additional chromosomal abnormalities. However multivariate analysis showed that neither additional chromosomal abnormalities overall nor any specific abnormality was identified as an independent risk factor for relapse.1 Tetraploidy or near-tetraploidy (NT), although very rare in acute promyelocytic leukaemia, has been described in more than 60 patients with acute myeloblastic leukaemia (AML).2 Only a few cases of tetraploid acute promyelocytic leukaemia with double t(15;17) have been reported so far.3–5 All the patients reported in the literature were of East Asian origin. In an observational study from China, the NT type with double t(15;17) was detected in five of the 660 patients (0.75%) over a 10 year period. All of the patients were men, with a median age of 38 years (range 21– 68).3 Giant and bizarre blasts were seen on bone marrow smears

Fig. 1 Bone marrow aspirate showing blasts, which are very large with bilobed, folded or cleaved nuclei and fine granular cytoplasm. Some blasts had multiple nuclear clefts.

folded or bilobed nuclei and fine granular cytoplasm. Many blasts had multiple nuclear clefts (Fig. 1). There were a few granular blasts also without any Auer rods. These morphological features were characteristic of microgranular variant of acute promyelocytic leukaemia. Flow cytometric immunophenotyping of bone marrow showed abnormal myeloid cell population of 90% with high forward and side scatter expressing CD33, CD117 and CD13 markers and negative for CD34 and HLA-DR markers, which is a classical immunophenotype in acute promyelocytic leukaemia. Bone marrow chromosome analysis demonstrated a male tetraploid karyotype (4n) containing two copies of a translocation between the long arms of chromosomes 15 and 17 in sixteen out of seventeen metaphases. The karyotype was 92,XXYY,t(15;17)(q22;q21) x 2[16]/46,XY[1] (Fig. 2). Fluorescence in situ hybridisation (FISH) analysis using the Vysis dual colour dual fusion PML/RARa probe (Abbott Molecular, USA) showed 4 copies of the PML/RARa gene fusion (Fig. 3). Reverse transcriptase polymerase chain reaction

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Fig. 2 Bone marrow cytogenetics demonstrated a male tetraploid karyotype (4n) containing two copies of a translocation between the long arms of chromosomes 15 and 17. The karyotype was 92,XXYY, t(15;17)(q22;q21)x2.

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VYSIS LSI PML/RARA dual colour fusion probe

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draw any useful conclusions, unlike with the other additional chromosomal abnormalities associated with acute promyelocytic leukaemia.1 Acknowledgement: We thank Professor Harry Iland, Molecular Haematology Laboratory, Royal Prince Alfred Hospital, Sydney, Australia, for providing molecular (RTPCR) services and giving his expert opinion in this case.

RARA

Conflicts of interest and sources of funding: The authors state that there are no conflicts of interest to disclose. PML FUSION

Fig. 3 FISH analysis using the Vysis dual colour dual fusion PML/RARa probe showed 4 copies of the PML/RARa gene fusion.

in all the patients.3,5 The immunophenotype of these blasts was similar to the patients with the isolated t(15;17) translocation, except that CD2 co-expression was noted in the majority of patients. In these patients with the tetraploid karyotype and double t(15;17), the response to treatment was reportedly similar to the patients with isolated t(15;17) translocation.3 To our knowledge this is the first reported case of tetraploid acute promyelocytic leukaemia in a patient of non-Asian ethnicity. The majority of the blasts were very large, as was noted in the other case reports, and many blasts had atypical morphology (multiple nuclear clefts). The patient had a very good initial response to ATRA and chemotherapy and he continued to be in complete molecular remission when last seen 12 months after the diagnosis. The mechanism of tetraploidy development and whether there is any effect on the longterm prognosis in such patients is not clear. The small number of such cases and rarity of this entity makes it difficult to

Muhajir Mohamed*{ Karen Dun{ *Haematology Department, Launceston General Hospital, Launceston, {Launceston Clinical School, University of Tasmania, and zCytogenetics Department, Royal Hobart Hospital, Hobart, Tas, Australia Contact Dr M. Mohamed. E-mail: [email protected] 1. Cervera J, Montesinos P, Herna´ndez-Rivas JM, et al. Additional chromosome abnormalities in patients with acute promyelocytic leukemia treated with alltrans retinoic acid and chemotherapy. Haematologica 2010; 95: 424–31. 2. Mitelman F, Johansson B, Mertens F, editors. Mitelman Database of Chromosome Aberrations and Gene Fusions in Cancer (2012). http://cgap. nci.nih.gov/Chromosomes/Mitelman. 3. Pan J, Xue Y, Qiu H, et al. Tetraploid clone characterised by two t(15;17) in five cases of acute promyelocytic leukaemia. Cancer Genet Cytogenet 2009; 188: 57–9. 4. Oh SH, Park TS, Kim HH, et al. Tetraploid acute promyelocytic leukemia with double t(15;17) and PML/RARa rearrangements detected by fluorescence in situ hybridization analysis. Cancer Genet Cytogenet 2003; 145: 49–53. 5. Wu WY, Ma SK, Lam CK, Chan LC, Kwong YL. Tetraploid acute promyelocytic leukemia with large bizarre blast cell morphology. Cancer Genet Cytogenet 1999; 115: 52–5.

DOI: 10.1097/PAT.0b013e32835c772c

Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.