A.W. Barrett

Marsupialization for lacrimal ductular cysts (dacryops): a case series.

Purpose: To present the clinicopathological features and treatment outcomes of lacrimal ductular cysts managed with marsupialization. Methods: Retrospective case review of 13 patients presenting with lacrimal ductular cysts. Results: Thirteen patients were identified, of which 7 patients with full clinical data were included in the study, 4 female, 3 male, mean age 50 years. Their main presenting symptoms were superolateral orbital swelling, feeling of pressure on the eye, and lateral ptosis. Two patients had bilateral cysts, and the remaining 5 had unilateral cysts. Six patients required surgical marsupialization, and one patient was treated conservatively because of preexisting dry eye. At surgery, one patient had multiple dacryoliths within the cyst. Histopathological analysis of the cyst lining in 5 out of 7 patients showed bilayered cuboidal epithelium with fibrous tissue. None of the patients had dry eye symptoms or signs after surgery. Follow-up ranged from 10 months to 2 years, mean 20 months Conclusion: Marsupialization is a safe and effective treatment for lacrimal ductular cysts.

Perivascular epithelioid cell tumor (PEComa) of the cheek

We present the unusual case of a perivascular epithelioid cell tumor (PEComa) occurring within the cheek of a 32-year-old woman. PEComa is a rare, recently described, family of tumors with diverse clinicopathologic expression and which express melanocytic and muscle markers. It mainly affects the abdominopelvic region and rarely occurs in somatic soft tissue or skin. To our knowledge, this is the first reported case of PEComa occurring in the facial cutaneous tissues. Other possible diagnoses considered included benign mesenchymal tumors of smooth muscle or neural origin. However, the cytomorphologic and immunohistochemical profile were most suggestive of PEComa. The tumor was completely excised, but in view of uncertainty as to how this entity would behave in an unusual location, lifelong follow up is recommended. After complete excision, there was no recurrence in 4 years.

Wegener's granulomatosis of the parotid gland and surrounding tissues.

egener’s granulomatosis (WG) is an idiopathic inflammaory disease which produces a systemic vasculitis. The head nd neck is involved in nearly 90% of cases, but the site sually affected is the upper airway.1 The other organs most haracteristically involved are the lungs and kidneys. Howver, WG can also present as a swelling or abscess of the eck, often in the area of the major salivary glands, usually he parotid. One or both sides can be affected.2–4 There are solated reports of sublingual5 and the lacrimal6 gland disase. Symptoms may be vague or masquerade as malignancy, nd when disease of the major salivary glands is the index resentation of WG the cause may remain unknown until ore typical features arise, as we describe in this report.

Malakoplakia of the face: A rare but important diagnosis

Malakoplakia that presents in the head and neck is rare. We describe a case in a man who presented with a fungating mass in the periauricular skin that was thought to be a malignant tumour. Histopathological and microbiological investigations established a diagnosis of malakoplakia.

Excision of periocular basal cell carcinoma guided by en face frozen section

We describe a technique for monitoring excision margins in periocular basal cell carcinoma (BCC) using en face frozen sections and report outcomes. We excised periocular BCC with 3mm margins. An outer 1mm sliver of the perimeter of the specimen was mapped and sent for evaluation by en face frozen section. The central tumour mass was processed using routine paraffin sections. A further 3mm level was excised at the site of any affected margin and the outer 1mm sliver was again evaluated by frozen section. We identified 78 patients from November 2003 to July 2009; 67 had primary tumours and 11 (14%) had recurrent BCC of which 52 (66%) were located on the lower eyelid. Growth patterns were nodular (n=34, 43%), infiltrative (n=25, 32%), micronodular (n=12, 16%), and superficial (n=7, 9%). A third of BCC with a clinically nodular appearance showed additional histological patterns including infiltrative and micronodular growth patterns. Of 30 clinically nodular carcinomas, 29 were excised completely with one level, and one required 2 levels of excision for clearance after evaluation by frozen section. Mean follow-up was 23 months (range 2-60). There was one recurrence (1%). Excision of margins guided by en face frozen section is justified by the low rates of recurrence, and it can easily be taught or imported into hospital practice. Clinically nodular BCC have subclinical extensions that can be missed on bread loaf sectioning, which makes the sampling of margins a standard for periocular BCC.

Dentigerous Cyst and Ameloblastoma of the Jaws: Correlating the Histopathological and Clinicoradiological Features Avoids a Diagnostic Pitfall.

Aim. To determine how many ameloblastomas were misdiagnosed as dentigerous cysts (DCs) by correlating the radiological and histopathological features of a series of both entities. Methods and results. Histopathology reports and radiological imaging of 135 DCs and 43 ameloblastomas were reviewed. Any clinical or radiological feature that suggested that the diagnosis of DC was wrong—for example, absence of an unerupted tooth—prompted review of the original histology. A total of 34 cases coded as DC at diagnosis were excluded; in the remaining 101 patients, the clinicoradiological and histopathological features were consistent with DC in 96 (95.0%). Review of the histology revealed that 4 patients had actually had odontogenic keratocysts (OKCs) and one a luminal/simple unicystic ameloblastoma (UA). One other OKC and 3 other ameloblastomas (1 luminal UA, 2 solid/multicystic) had originally been diagnosed as DC; these had been identified prior to the study. Of the 9 misdiagnosed patients, 6 were ≤20 years old. Clinically, DC had been the only, or one of the differential, diagnoses in 7 patients; in the other 2, the clinical diagnosis was radicular cyst. In none of the 4 misdiagnosed ameloblastomas was the radiology compatible with a diagnosis of DC. Incorrect terminology had been used on the histopathology request form in 5 of the 34 excluded cases where the clinical diagnosis was DC, despite the cyst being periapical to an erupted carious or root-filled tooth. Conclusions. The entire clinical team must ensure that a histopathological diagnosis of DC is consistent with the clinicoradiological scenario, particularly in younger patients.

Bilateral Asynchronous Renal Cell Carcinoma with Metastatic Involvement of the Tongue

Renal cell carcinoma (RCC) has a propensity for distant organ metastasis and late recurrence, involving not only the ipsilateral but also contralateral kidney. Lingual metastasis by RCC is rare. We present an unusual case of bilateral asynchronous RCC. Involvement of the right kidney was discovered only after a metastatic tongue lesion was diagnosed. The original RCC had been treated by left nephrectomy 14 years previously. Due to end-stage primary pulmonary malignancy, and poor function of the remaining kidney, immunotherapy was unsuitable. Palliative local resection of the lingual metastasis alleviated functional difficulties and was preventative against airway obstruction, but the patient died five months later.

Staging of squamous cell carcinoma of the tongue: extrinsic lingual muscles and the 8th editions of the American Joint Committee on Cancer/Union for International Cancer Control staging manuals

Our aim was to find out first whether the extrinsic muscles of the tongue are histologically identifiable, and secondly to what degree the use of the new criteria in the 8th editions of the American Joint Committee on Cancer(AJCC)/Union for International Cancer Control (UICC) manuals (which have recognised the importance of depth of invasion of tumour, rather than invasion of the extrinsic muscles of the tongue and extranodal extension), will alter staging of lingual squamous cell carcinoma (SCC). The histological sections from 165 patients who had had primary resection of lingual SCC were reviewed, and one or more extrinsic muscles of the tongue was identified in 100 patients (61%), with the genioglossus seen the most often (in 96). By contrast, the hyoglossus was identified in only eight patients, the styloglossus in two, and the palatoglossus in none. Identification was straightforward only in extensive resections. Applying the criteria from the 8th edition increased the number of pT3 SCC with a simultaneous reduction in pT4a tumours. The number of pN2b SCC was also reduced, but the new category of pN3b meant that overall 53% of tumours were upstaged. The kappa scores for agreement between the two sets of criteria were 0.221 (weighted 0.410) for the pT values, 0.508 (0.713) for pN values (but 0.227, weighted 0.386, if the pN0 values were removed before calculation), and 0.243 (0.514) for overall stage, indicating poor to fair agreement. We conclude that the removal of invasion of extrinsic muscles of the tongue as a criterion for a pT4a SCC is justified, and that many SCC of the tongue will be upstaged as a result of implementation of the 8th editions.

Synchronous metastatic adenoid cystic and squamous cell carcinoma of the cervical lymph nodes 31 years after ablation of the primary palatal tumour

The coexistence of different types of malignancy in cervical lymph nodes has been reported previously. We report the first case, to the best of our knowledge, of concurrent metastatic adenoid cystic carcinoma and squamous cell carcinoma (SCC) in cervical lymph nodes. A primary SCC developed three decades after treatment for adenoid cystic carcinoma of the palate, and the synchronous metastases became clinically apparent the following year. The aetiology of the SCC may have been related to radiotherapy or smoking. Whether the adenoid cystic carcinoma would have remained dormant, or was reactivated after perturbation of host defence mechanisms, is not known.