Faculty Bibliography

The presence of glandular epithelium in urinary tract biopsies poses a diagnostic challenge. Intestinal metaplasia of the urethra may be seen in many congenital, iatrogenic, and reactive conditions, as well as in association with malignant conditions such as urethral adenocarcinoma. We present a case of a 61 year-old woman presenting with microscopic hematuria. Successive biopsies showed glandular epithelium with focal atypia in close association with inflammation, but no overt malignancy. Only on surgical resection was the associated high grade adenocarcinoma revealed. When intestinal-type mucosa is present within a urinary tract biopsy, associated malignancy may be present only focally. Thorough sampling and consideration of the differential diagnosis is imperative.

Tubulocystic renal cell carcinoma (TC-RCC) is a rare renal tumor composed of well-differentiated tubules and cysts lined by neoplastic cells with eosinophilic cytoplasm and prominent nucleoli. The origin of the tumor cells is still controversial. TC-RCC typically arises unilaterally. Involvement of both kidneys by multifocal TC-RCC has not been reported. In this study we report the first case of bilateral and multifocal TC-RCC. Immunohistochemical, cytogenetic and ultrastructural studies suggest TC-RCC is closely related to papillary RCC.

Tubulocystic renal cell carcinoma (TC-RCC) is a rare, typically unilateral renal tumor. We report the first case of bilateral multifocal TC-RCC associated with end-stage renal disease with cytogenetic, immunohistochemical, and ultrastructural studies. A 62-year-old man with type 2 diabetes, hypertension, and end-stage renal disease on hemodialysis had bilateral complex renal masses smaller than 3.0 cm in greatest dimension found incidentally. Follow-up imaging studies demonstrated slowly enlarging masses. The patient underwent bilateral laparoscopic radical nephrectomy. Grossly, both kidneys had multifocal, unencapsulated, sharply demarcated, gray, spongy cystic lesions (0.3-2.5 cm) in cortex and medulla. The lesions contained clear serous fluid. Microscopically, the background kidneys showed end-stage changes with glomerulosclerosis and atrophic tubules. The well-delineated cystic lesions are composed of tightly packed tubules and cysts, separated by bland fibrous stroma. The lining cells are single-layer, flattened, cuboidal to columnar, with abundant eosinophilic cytoplasm, large round to oval nuclei, and prominent nucleoli. Hobnail cells are common. No desmoplastic reaction or cellular ovarian-like stroma is present. No solid growth or papilla is seen in either kidney. Immunohistochemically, the tumor cells showed diffuse and strong positivity for AMACR, AE1/AE3, CK8/18, CD10, and PAX2; focally strong positivity for CK7, EMA, vimentin, and 34BE12; and negativity for p63 and CK20. TC-RCC was diagnosed. Fuhrman nuclear grade was 2 to 3. Pathologic stage was pT1 on both kidneys. Fluorescence in situ hybridization shows gain of chromosome 7 and chromosome 17. Transmission electronic microscopy showed 2 types of epithelial cells: type I cells reminiscent of proximal tubular cells and lining the tubules and type II cells reminiscent of distal tubular cells lining the cysts. The patient was disease-free 3 years after radiologic detection and 12 months after bilateral nephrectomy. Our studies suggest TC-RCC is closely related to papillary RCC. This tumor appears to be low-grade with no metastasis

Rosai-Dorfman disease is a rare, benign histiocytic proliferative disorder that commonly affects the lymph nodes. Although extranodal involvement has been reported in diverse sites, manifestation in the cardiovascular system is extremely uncommon. Specifically, the involvement of the heart by Rosai-Dorfman disease is an extraordinarily infrequent event. Here, the authors present a case of Rosai-Dorfman disease arising in the right atrium in a symptomatic 61-year-old man who initially presented with pleuritic chest pain and was found to have a large, lobulated, and circumscribed right atrial mass. The lesion exhibited an exuberant histiocytic and chronic fibroinflammatory process with focal emperipolesis within histiocytes. Immunohistochemical studies demonstrated strong S100 positivity in CD68+ CD1a- histiocytes. Although rare, Rosai-Dorfman disease should be considered in the differential diagnosis of a right atrial mass

A 60-year-old male presented with complaints of dizziness, which worsened with fatigue and a sense his balance was 'off'. Initial physical examination was negative and the laboratory testing was unremarkable. Within weeks, the patient developed bilateral visual field deficits. MRI revealed an extra-axial mass which extended into the pituitary fossa and caused compression of the pituitary gland. The pituitary stalk was displaced posteriorly and the optic chiasm was compressed with displacement superiorly and posteriorly. The patient underwent a surgical resection. Diabetes insipidus developed postoperatively requiring a vasopressin drip. He also developed hypopituitarism after the resection with hypothyroidism, hypoadrenalism and hypogonadism. The patient requires testosterone, levothyroxine and hydrocortisone replacement and has mild residual bitemporal hemianopsia.

A case of metastatic balloon cell malignant melanoma (BCMM) is presented. The balloon melanoma cells (BMC) were absent in the shave biopsy of the primary lesion and present as a minor component in the wide and deep excision. A subsequent right neck lymph node metastasis showed complete replacement of the lymph node by large, foamy cells. Though the tumor was amelanocytic and Fontana-Masson stain failed to reveal melanin, it stained positively for S-100, HMB-45, and Melan-A. Ultrastructurally, the foamy cells were characterized by cytoplasmic vacuolization and a lack of melanosomes. The differential diagnosis of metastatic balloon cell malignant melanoma is broad, and clinicopathologic correlation may play a critical role in achieving the correct diagnosis

Carney complex is a syndrome that may include cardiac and mucocutaneous myxomas, spotting skin pigmentation, and endocrine lesions. Many patients with Carney complex have been shown to have a stop codon mutation in the PRKAR1A gene in the 17q22-24 region. Here we present the case of a 57 year-old man with multiple skin lesions and cardiac myxomas. Histology of the skin lesions showed lentigenous melanocytic hyperplasia and cutaneous myxomas, confirming the diagnosis of Carney complex. Lesional and control normal tissue from the patient were identified and sequenced for the PRKAR1A gene. A germline missense mutation was identified at exon 1A. This is the first report of this mutation, and one of the few reported missense mutation associated with Carney complex. This finding strengthens the argument that there are alternative ways in which the protein kinase A 1-alpha subunit plays a role in tumorigenesis

ABSTRACT: Pulmonary involvement and skin involvement are rare complications of plasma cell neoplasms. Here we describe what may be the first reported case of a patient with relapse in both of these sites following autologous peripheral blood stem cell transplantation