Metastatic breast carcinoma involving the thyroid gland diagnosed by fine-needle aspiration: a case report

Secondary involvement of the thyroid gland from a remote primary malignancy is uncommon. The distinction of metastatic carcinoma (MC) or sarcoma from a primary thyroid malignancy is important because the treatment is different. We discuss a case of a 64-yr-old female with a history of breast carcinoma, who presented with pain and swelling in her neck 5 yrs after being diagnosed with breast cancer. She had undergone mastectomy with subsequent chemotherapy and radiation for infiltrating mammary carcinoma. During the 5-yr interval, she had been free of clinically evident metastatic disease. Subsequent work-up revealed two distinct nodules in the left lobe of her thyroid gland as well as a subcutaneous mass in her right shoulder. A fine-needle aspiration (FNA) of the larger thyroid nodule showed malignant epithelial cells with features consistent with breast carcinoma in a background of benign thyroid epithelial cells and colloid. The case was signed out as metastatic breast carcinoma. Subsequent FNA and biopsy of her right shoulder lesion also revealed metastatic breast carcinoma with similar morphology to the material in the thyroid FNA.     

Primary eyelid angiosarcoma in a Chinese patient

Purpose: To describe a case of primary eyelid angiosarcoma and review the literature to emphasize aware of this rare disease. Case Report: We report a further case which is the first Chinese primary eyelid angiosarcoma in the literature. A 76-year-old woman presented with a 6-month history of a painless lesion on her left eyelid. The patient finally proved to be angiosarcoma on histopathologic and be treated with complete surgical excision with a frozen section margin control. With a 6 months follow-up, we haven’t found any symptoms of recurrence or metastasis. Conclusions: Cutaneous angiosarcoma with eyelid is a rare, soft-tissue sarcoma of endothelial cell origin that is aggressive malignancy and has a poor prognosis. In our case report, the patient was treated with complete surgical excision with a frozen section margin control, and a 6 months follow-up, we haven’t found any symptoms of recurrence or metastasis.     

FNA diagnosis of recurrent sebaceous carcinoma

We describe fine-needle aspiration (FNA) diagnosis in a case of sebaceous carcinoma presenting as recurrent swelling eyelid. The patient, a 35-yr-old woman, presented with a gradually increasing painless mass in the left upper eyelid. She had a history of excisions of swelling at the same site over a period of 5 years. On FNA, the smears were cellular and demonstrated sheets, three dimensional clusters, and singly scattered polygonal tumor cells having centrally located hyperchromatic and pleomorphic nuclei and cytoplasmic microvacuolations. Oil red-O stain performed on air-dried smears showed positivity, confirming the presence of intracellular and extracellular lipid globules. A final impression of sebaceous carcinoma of the left upper eyelid was rendered, based on which the eyelid mass was radically excised. Subsequent histopathology confirmed the diagnosis. Despite wide excision, such tumors not uncommonly recur and metastasize. An early and accurate diagnosis of such lesions can be established on minimally invasive needle aspiration.     

Atypical presentation of calvarial metastasis of renal cell carcinoma in an adolescent: A rare case diagnosed on fine needle aspiration cytology with literature review

Renal cell carcinoma (RCC) is a complex and challenging neoplasm both in terms of treatment as well as diagnosis. Its unpredictable biological behavior and many deceptive appearances can sometimes bewilder the pathologist. We hereby report a rare case of a 17 year old girl presenting with an occipital swelling and importantly no prior documents at the time of aspiration. Fine needle aspiration cytology showed features of metastatic carcinoma with the following possibilities; metastatic RCC, melanoma, and hepatocellular carcinoma. Further detailed history of the patient and investigations were advised. Intraoperative squash smears also showed similar features. Histopathology of the lesion showed features of metastatic RCC. This case highlights the fact that a skull lesion in rare cases may be the presenting sign of an underlying malignancy. In the absence of key documents, providing the correct diagnosis may become very challenging and cytomorphology alone can be extremely helpful. Diagn. Cytopathol. 2015;43:412–415. © 2015 Wiley Periodicals, Inc.     

Tumor-to-tumor metastasis (TTM) of breast carcinoma within a solitary renal angiomyolipoma: A case report

Angiomyolipomas of the kidney have been known to harbor malignant neoplasms including renal cell carcinoma. We report a case of a tumor-to-tumor metastasis (TTM) involving metastatic breast carcinoma and angiomyolipoma. The patient was a 67-year-old female with a history of invasive ductal carcinoma of the breast. Follow-up positron emission tomography 9 years later revealed a left renal mass, suspicious for a primary renal neoplasm, as well as a suspicious subpectoral lymph node. An ultrasound-guided needle biopsy of the lymph node demonstrated metastatic breast carcinoma. The patient underwent a left radical nephrectomy. Pathologic examination demonstrated an ill-defined 2 cm estrogen receptor (ER)-positive metastatic breast carcinoma within a 6 cm angiomyolipoma. To our knowledge, this is the first reported case of metastatic breast carcinoma to a solitary renal angiomyolipoma. This case highlights the importance of a patient's prior history of malignancy, as well as appropriate sampling of renal neoplasms.     

Synchronous bony and soft tissue metastases from follicular carcinoma of the thyroid

Follicular carcinoma of the thyroid rarely manifests itself as a distant metastatic lesion, and, when present, is usually found in flat bones. A soft tissue metastasis is extremely rare, and synchronous metastases to the bone and soft tissue is not reported in the literature so far. We report such a case of a 42-yr-old male, who presented with a goiter, scalp and forearm soft tissue swellings, and, fine needle aspiration cytology of all these swellings revealed a follicular neoplasm. A wide excision of the forearm swelling was carried out and the histopathology was consistent with features of metastatic follicular carcinoma of the thyroid. The main stay of treatment is surgical resection of the primary tumor. The various modalities of treatment of metastasis is discussed with a review of literature.     

Breast cancers with extremely high oestrogen receptor protein status

Seventeen cases of primary and one case of metastatic breast cancer which expressed greater than 900 fmol oestrogen receptor sites per mg soluble protein were examined. All these patients were post-menopausal at the time of their presentation. These were a heterogeneous group of well-differentiated cellular breast carcinomas, comprising cases of invasive duct carcinoma with extensive tubular differentiation or with focal argyrophilia, tubulolobular carcinoma, lobular carcinoma of mixed type containing abundant intracytoplasmic lumina, papillary carcinoma and type B colloid carcinoma. There was very little tumour necrosis. Nodal metastasis, tumour size and host inflammatory response did not appear to show any relationship with oestrogen receptor status. The patients, apart from two who died from other causes, remain alive (Fisher's exact test, P less than 0.01). In contrast, 17 randomly selected cases of oestrogen receptor negative breast cancer in the same study period were focally necrotic, poorly-differentiated invasive duct carcinomas. Six patients died from metastatic disease, seven were alive and well, one was alive with metastatic disease, one was lost to follow-up and two died from diseases unrelated to breast cancer.     

Bilateral choroidal metastases as the initial presentation of breast carcinoma

A 64 year old female presented with a right eye visual impairment. On examination, the visual acuity was decreased on the right side. Slit lamp examination showed bilateral non-pigmented choroidal lesions. Physical examination was unremarkable; bilateral mammogram, however, showed a mass in the left breast, the biopsy from which confirmed the lesion as infiltrative carcinoma. Other tests were normal apart from the isotope bone scan which showed evidence of metastatic disease. She received a short course of radiotherapy to both eyes as well as a 6-month course of chemotherapy. At 6 months follow-up, the choroidal lesions were no longer present and the visual acuity had stabilized. Choroidal metastasis as the initial presentation of breast carcinoma is unusual. Any patient with an ocular tumour should undergo a systemic check-up to rule out an underlying malignancy.     

Metastatic follicular thyroid carcinoma to the thymus in a 35-year-old woman

Clinically detectable metastatic follicular thyroid carcinoma to the thymus is very rare in the literature and sometimes confused with false positive uptake of Iodine(131) (I(131)) in the normal thymus or hilar lymph node. The authors report a 35-year-old woman with metastatic follicular carcinoma to the thymus. She underwent total thyroidectomy and I(131) ablation with 200 mCi. Six months later, a follow-up I(131) whole body scan showed continued radioactive iodine uptake in the retrosternal area and the serum thyroglobulin level remained continuously elevated with levothyroxine suppression therapy (22.3 and 36.4 ng/ml, 6 and 10 months after total thyroidectomy, respectively). CT scan of the chest revealed several aggregated cystic lesions in the retrosternal mediastinum, suspected to represent mediastinal metastasis. The surgically resected retrosternal mass was confirmed as a metastatic follicular carcinoma to the thymus. After surgical excision, the serum thyroglobulin level was below 1.0 ng/ml and I(131) whole body scan showed no radioactive iodine uptake in the mediastinum. The patient showed no evidence of recurrence after excision of thymic metastasis during one year of 0.2 mg levothyroxine suppression therapy. We report a case of metastatic follicular thyroid carcinoma to the thymus without bone or pulmonary involvement.     

Extramammary Paget's disease with aggressive behavior: a report of two cases.

Extramammary Paget's disease (EMPD) is an intraepithelial neoplastic disorder which is included as a rare malignant condition. However, it sometimes shows aggressive behavior of local recurrence and coexisting malignancy. We had experienced nine cases of EMPD involving the scrotum for seven years. Two cases of them presented metastasis. The first case presented extensive inguinal lymph node metastasis with underlying adnexal adenocarcinoma one year after wide local excision. The second case initially presented multiple metastasis to the liver and in the lymph node. The latter, showing fulminant progression with liver metastasis, may be only the second case reported in English literature. EMPD is considered as a malignant neoplasm with aggressive behavior from initial presentation. Because wide local excision of the lesion alone may be occasionally insufficient, a careful follow-up must be done to detect recurrence or internal malignancy.     

Collision sebaceous and basal cell carcinomas of the eyelid

OBJECTIVE: To report a rare case of collision sebaceous and basal cell carcinomas of the eyelid. DESIGN: Interventional case report. METHODS: An 80-year-old woman presented with a nodular lesion at the center of the left lower eyelid. Small ulceration and madarosis were also present. RESULTS: The patient underwent excisional biopsy with frozen section control. Histopathology showed mixed sebaceous as well as basal cell carcinoma with uninvolved surgical margins. Oncologic survey did not disclose any other lesion. At 6-month follow-up, there was no evidence of recurrence, new lesions, or metastasis. CONCLUSION: Sebaceous and basal cell carcinomas can coexist in the eyelid within the same clinical lesion. Because of the potential risk of metastasis of sebaceous carcinoma, close follow-up of the patients is advisable.     

Histiocytic appearance of metastatic lobular breast carcinoma

Autopsy findings in a case of widely disseminated lobular breast carcinoma showed an unusual histiocytoid appearance in metastases to the uterus and parathyroid gland. This morphology for breast carcinoma has been previously reported in eyelid metastases. Recognition of this pattern in other metastatic sites has important diagnostic and therapeutic implications. Problems might have arisen if the polypoid uterine mass had been the presenting lesion during life. We also review the occurrence of metastatic breast carcinoma in the uterus and parathyroid gland.     

Recurrent endocrine mucin-producing sweat gland carcinoma

Endocrine mucin-producing sweat gland carcinoma is a rare skin tumor that most commonly involves the eyelid of elderly women. Morphologically and immunohistochemically, it is analogous to endocrine ductal carcinoma in situ of the breast and mammary solid papillary carcinoma; also, like the analogous breast lesion, there is an often associated invasive mucinous carcinoma with neuroendocrine differentiation. We describe the case of a 65-year-old woman with endocrine mucin-producing sweat gland carcinoma of the eyelid that recurred 3 years after an apparently complete excision.     

Signet ring cell carcinoma of the breast

A rare case of signet ring cell (SRC) carcinoma of the breast occurring in a 51-year-old female is presented. She was first admitted under the diagnosis of gastric carcinoma. Incidentally, a right breast tumor was detected and double cancer was thus suspected clinically. Concurrent right mastectomy and partial gastrectomy were performed. Histologic examination on the removed tumors revealed infiltration of numerous SRCs. The signet ring appearance of tumor cells resulted from formation of a large intracytoplasmic globule. From this unique cytologic feature along with the presence of in situ lesion in the breast tumor, it was concluded that the gastric malignancy was a sequela of metastasis of infiltrating lobular carcinoma. Wide-spread metastasis later occurred, especially on the serosal surfaces. The importance for the knowledge about the unique metastatic pattern of SRC carcinoma of the breast was emphasized.     

Parotid or carotid? Misled by site

We present an interesting scenario where a 64 years old male presented with a long standing painless, infra‐auricular swelling, which had progressively increased in size. Based on the site, the clinical impression was of a salivary gland lesion and FNAC was performed. The smears were unusually cellular and had necrotic background. The cytological diagnosis was a cystic neoplasm of salivary gland, possibly mucoepidermoid carcinoma. Warthin's tumor was also kept in differential. However, the radiological investigations, which were made available after the FNAC report were conflicting with cytological diagnosis of a malignancy and were characteristic of a carotid body tumor, generally a benign neoplasm. Surgical excision of the tumor with regional lymph node sampling was done and histopathological examination solved the puzzle by revealing metastasis of paraganglioma to right posterior triangle lymph nodes. This case is unique because of the unusual presentation of a malignant paraganglioma as an infra‐auricular swelling, which was clinically considered as a parotid tumor. The clinician as well as the pathologist need to be aware of such diagnostic pitfall. Diagn. Cytopathol. 2017;45:569–573. © 2017 Wiley Periodicals, Inc.     

Primary and metastatic high-grade carcinomas of the salivary glands: A cytologic-histologic correlation study of twenty cases

We reviewed the clinical and fine-needle aspiration (FNA) findings in 20 patients with poorly differentiated carcinomas presenting initially as parotid or as submandibular masses. There were 11 primary tumors and nine metastatic malignancies in 14 males and six females ranging in age from 39 to 89 yr (median = 66). The tumor types included three primary carcinomas with oncocytic features, three additional cases of high-grade parotid carcinoma, one case of primary neuroendocrine carcinoma, two examples of malignant mixed tumor, one high-grade mucoepidermoid carcinoma, and a single example of malignant lymphoepithelial lesion. Six patients with metastatic carcinoma had previous diagnoses of malignancy. In the three remaining individuals, primary carcinomas of the lung (two cases), and an unknown primary site presented initially as parotid masses. Five examples of metastatic squamous cell carcinoma, one metastatic basal cell carcinoma, and two metastatic renal cell carcinomas were identified. One parotid lymphoepithelioma was interpreted cytologically as an atypical lymphoproliferative process suggestive of Hodgkin's disease. Nineteen cases (95%) were correctly classified as carcinoma at the time of FNA. High-grade carcinomas aspirated from the parotid may be primary, but are frequently metastatic to either the gland, or to an intraparotid lymph node. Our experience indicates that some metastatic carcinomas present at this site, without a previous history of malignancy. Distinguishing primary from metastatic lesions has important therapeutic implications. © 1995 Wiley-Liss, Inc.     

Unilateral localized conjunctival amyloidosis in a patient with a history of contralateral orbit/eyelid lymphoma

Amyloidosis is a disorder characterized by the deposition of insoluble abnormal proteins in the extracellular space. It may occur as a localized lesion or as a systemic disease involving multiple organs and systems. Localized conjunctival amyloidosis is rare and is less frequently associated with systemic involvement. Although amyloidosis itself is a benign lesion involvement of multiple organs and systems is associated with poor prognosis. Diagnosis of amyloidosis is made on biopsy specimens with Congo red staining for the appearance of apple-green birefringence under polarized light microscopy. Liquid chromatography tandem-mass spectrometry (LC-MS/MS) is much more sensitive in diagnosing amyloidosis and can determine the type of amyloid deposit. Here we reported a case of conjunctival amyloidosis in a 52?year-old male patient who was presented with left lower eyelid swelling to our medical center. He has a complicated past medical history of anti-phospholipid antibody syndrome, Buerger's disease (thromboangitis obliterans), and small cell lymphoma (SLL) of the right orbit/eyelid. The patient received radiation to the right orbit to treat SLL with therapy completed one and a half years prior to presentation. Physical examination revealed a firm, raised yellowish colored lesion in the left lower conjunctiva. The conjunctival lesion was biopsied, and tissue sections were examined with Congo red stains and LC-MS/MS analysis. The biopsy showed amyloid deposits without evidence of malignancy, and the type of proteins in the deposit was immunoglobulin light chain (AL) of kappa type. A complete work up was taken for possible systemic involvement of amyloidosis and results were all negative. To our knowledge, this is the first case of localized conjunctival amyloidosis with a history of contralateral orbit/eyelid SLL.     

Diagnosis of extramammary malignancy metastatic to the breast by fine needle biopsy

Aims: To review and illustrate the findings in fine needle biopsy (FNB) of extramammary malignancies presenting with breast metastases (MMB). Methods: We reviewed 32 cases of MMB diagnosed on breast FNB. The clinical data, with particular attention to the history of a known primary malignancy, previous systemic metastatic disease in other sites and presentation with extramammary disease in addition to a breast mass were examined. The morphological appearances were reviewed and are illustrated, focusing on those features which allow the pathologist to recognise the possibility of metastatic disease and undertake appropriate steps to investigate this. Results: The 32 cases included metastases from a wide range of sites, including cutaneous melanoma (10), lung (8), non-Hodgkin's lymphoma (5), soft tissue (4), colon (2), endometrium, ovary and bladder. There was a history of extramammary malignancy in 26, while in six patients the breast mass was detected at initial presentation with malignant disease. Of the latter six patients, four had evidence of widespread metastases, while one presented with multiple breast masses. In 16 cases the cytological features allowed the possibility of metastases to be recognised without clinical data, while in the other 16 there was sufficient overlap with primary mammary carcinoma that the possibility of metastases could be missed. Only one case was initially mistaken for a primary tumour, in this case the history of prior malignancy with systemic metastases was not provided to the reporting pathologist. Conclusion: The majority (81%) of cases of MMB have a history of primary malignancy, although only a minority have a history of systemic metastases at other sites. Of those patients without known prior malignancy, the majority present with systemic disease or multiple breast lesions. The cytological features allow metastatic disease to be suspected in half of the cases, although in the others, particularly patients with metastatic adenocarcinoma, diagnosis without recourse to immunohistochemistry is difficult or impossible. A combination of complete clinical history, attention to the cytological features and suspicion in cases with metastatic disease beyond the axilla should allow most cases of MMB to be suspected, and suitable material for ancillary confirmatory testing to be obtained.     

Ductopapillary apocrine carcinoma of the eyelid metastatic to the parotid gland: Report of a case diagnosed by fine‐needle aspiration biopsy

Ductopapillary apocrine carcinoma (DPAC) of the eyelid is a rare malignant neoplasm in the periocular region. The relative rarity of this tumor is a diagnostic challenge to the cytopathologist, especially when present as a metastatic lesion to an intraparotid lymph node, where the differential diagnosis includes primary parotid neoplasms, as well as various other metastatic malignancies. There are only a few reported cases of recurrent and metastatic DPAC of the eyelid, and to our knowledge, metastatic DPAC diagnosed by fine‐needle aspiration biopsy (FNAB) has not been described. We report a case of a 65‐year‐old African‐American male with a history of ductopapillary apocrine adenocarcinoma of the eyelid, diagnosed 6 weeks ago now presenting with a recurrence in the same area. Magnetic resonance imaging of the head and neck revealed an intraparotid mass also. FNAB of the parotid mass showed a well‐differentiated papillary adenocarcinoma with a cystic component, similar to a previously excised ductopapillary apocrine adenocarcinoma of the eyelid. Diagn. Cytopathol. 2009. © 2008 Wiley‐Liss, Inc.     

Unusual small bone metastases from epithelial malignancies: Diagnosis by fine-needle aspiration cytology with histologic confirmation

Although epithelial malignancies can have bone metastases, involvement of small bones is exceedingly rare, representing either first manifestation of an occult carcinoma or late disseminated disease. Small bone metastases may mimic primary skeletal diseases leading to misdiagnosis and delayed treatment. We report three cases of metastatic epithelial malignancies diagnosed by computed tomography (CT)-guided fine-needle aspiration (FNA) biopsy in two patients with lytic calcaneal lesions and a patellar lesion in a third patient; all with histologic confirmation. Case 1, a 63-yr-old female, presented with heel pain. FNA and tissue biopsy of the calcaneus revealed a clear cell malignancy consistent with a renal primary. Follow-up abdominal CT scan revealed a renal lesion consistent with renal cell carcinoma. Case 2, a 37-yr-old male with squamous cell carcinoma of the esophagus, presented with foot pain. FNA and tissue biopsy of the calcaneus revealed metastatic squamous cell carcinoma. Case 3, a 52-yr-old male with a history of squamous cell carcinoma of floor of mouth, presented with knee pain and swelling. FNA and tissue biopsy of the patella revealed metastatic squamous cell carcinoma. To the best of our knowledge, this is the first complete FNA cytology report with histologic confirmation of unusual small bone metastases of the feet and patella from epithelial malignancies and shows the value of FNA cytology in establishing a correct diagnosis, and excluding primary skeletal diseases. © 1995 Wiley-Liss, Inc.