Alia Nazarullah

Incidence and aetiologies of pulmonary granulomatous inflammation: A decade of experience

Granulomatous lung disease (GLD) is caused by a wide range of conditions. Often there is a need to correlate pathological findings with clinical, microbiological or radiological data to determine an aetiology. The aim of this study was to determine the different aetiologies of GLD over the past decade.

Cardiac inflammatory myofibroblastic tumor: a comprehensive review of the literature.

Although inflammatory myofibroblastic tumors (IMTs) can be found in virtually every major organ, cardiac origin is rare. After recently providing care to a child who presented with a significant myocardial infarction, interest in this rare tumor was piqued. We describe a comprehensive review of cardiac IMT, including information on nomenclature, epidemiology, clinical features, pathogenesis, gross/histological features, immunohistochemical profile, diagnosis, treatment, and prognosis. Fifty-seven cases were identified in the literature. Interestingly, our case represents the seventh case of coronary artery involvement reported. Moreover, it was found that an initial presentation of sudden death most commonly involves the coronary arteries.

Nodular histiocytic and mesothelial hyperplasia.

A 60-year-old man was found to have a 1.5-cm pericardial cyst during coronary artery bypass graft surgery. The cyst lined by monolayered mesothelium is associated with nodular clusters of round or polygonal cells with ample pale to pink cytoplasm and twisted or grooved nuclei (Figures A1 and A2). Lymphocytes, plasma cells, and neutrophils are sprinkled around these nodules. The lining mesothelium is positive for cytokeratin and calretinin (Figure A3) and the cell clusters are reactive for CD68 (Figure A4) and nonreactive for cytokeratin confirming their histiocytic nature. These histopathologic features are characteristics of nodular histiocytic/mesothelial hyperplasia (NHMH). NHMH was initially reported in hernia sacs and in other mesothelium-lined surfaces. Rarely, NHMH may occur in structures not known to harbor mesothelium such as the endocardium and inside dissecting aneurysm. NHMH is a benign lesion with no sex or age predilection. It is postulated that NHMH is a reactive process. In nonmesothelial areas, inadvertent introduction of mesothelial cells may have preceded the lesion. Cytologic atypia of the component cells have been demonstrated in some cases, which led to consideration of malignant entities. Awareness of the existence of NHMH and its benign nature helps prevent a diagnosis of malignancy and its attendant radical management. 418644 IJSXXX10.1177/1066896911418644Nicolas et alInternational Journal of Surgical Pathology

Metastatic breast cancer with GATA3, CK7 and ER positivity? A diagnostic pitfall

Introduction: Carcinoma of unknown primary can often be a challenge for clinicians and pathologists, and immunohistochemical stains (IHC) are often used as a useful diagnostic aid to narrow down the primary site of origin. In this context, co-expression of CK7, GATA3 and ER is highly suggestive of metastatic carcinoma from breast primary. This case highlights a major diagnostic pitfall in the interpretation of these stains. Case Report: A woman in her fifth decade presented with a possible thoracic vertebral lesion. The core biopsy showed cortical bone and a detached tissue with polygonal cells with eosinophilic cytoplasm and atypical,hyperchromatic nuclei with mild pleomorphism. These cells were strongly positive for CK7, GATA3, patchy positive for ER, and negative for CDX2, CK20, TTF1, thyroglobulin, mammaglobin, Melanin A, and PAX8 IHC stains. The interpretation based on these findings was metastatic breast adenocarcinoma. The patient received tamoxifen for stage 4 ER-positive breast cancer, in spite of no clinical or radiologic findings of a breast lesion. A 16 months after Diane-Ngan Trang1, Hongbo Wang2, Marlo Nicolas3, Alia Nazarullah1 Affiliations: 1Department of Pathology and Laboratory Medicine, University of Texas Health, 7703 Floyd Curl Drive, MC#7750, San Antonio, Texas, USA; 2Department of Pathology, Baylor Scott & White Medical Center, 2401 S. 31st Street, MS-01-266, Temple, Texas, USA; 3Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA. Corresponding Author: Alia Nazarullah, M.D., Assistant Professor/Clinical,Department of Pathology and Laboratory Medicine, University of Texas Health, 7703 Floyd Curl Drive, MC#7750, San Antonio, Texas, USA 78229; Email: nazarullah@uthscsa.edu Received: 22 June 2018 Accepted: 01 August 2018 Published: 10 August 2018 the initial diagnosis, the patient was referred to our institution. We noted prominent blood vessels and a few compressed glands positive for PAX8 resembling inactive endometrial glands within the detached fragment containing the atypical cells. The fact that intermediate and cytotrophoblasts express GATA3, cytokeratins and ER, along with the presence of inactive endometrial-type glands led us to conclude that the detached tissue likely represents a contaminant from an endometrial implantation site. Conclusion: This case reminds us that the immunohistochemical profile of trophoblasts is very similar to breast, and can cause major diagnostic pitfalls leading to erroneous diagnosis of metastatic breast cancer with severe consequences. IHC stains are not always specific, and should always be interpreted in the context of morphology.

Pulmonary Adenocarcinoma, Intra-alveolar Variant: A Rare Entity Mimicking Desquamative Interstitial Pneumonia

Exclusive discohesive tumor cells within intra-alveolar spaces is a rare pattern of involvement of primary and metastatic lung tumors. In the absence of a tumoral mass, this pattern closely mimics desquamative interstitial pneumonia (DIP) clinically, radiologically, and histologically. However, a secondary DIP pattern may be seen adjacent to a tumor mass not infrequently. Here, we describe a case of a 64-year-old woman status post bilateral lung transplantation, who was radiologically thought to have an interstitial lung disease. The autopsy lung specimen revealed extensive involvement by intra-alveolar adenocarcinoma, with a cytomorphology mimicking alveolar macrophages as seen in DIP in the absence of a tumoral mass. The presence of subtle clustering with signet ring cell features and rare micropapillae were an important clue to the diagnosis. The tumor cells were positive for CK7, napsin-A, and TTF-1, and negative for CD68. This case represents an unusual variant of pulmonary adenocarcinoma with a pure intra-alveolar pattern of involvement, mimicking DIP. To the best of our knowledge, excluding biopsy specimens, only one similar case has been reported in the literature and none in the posttransplant setting.

Bilateral conjunctival pediatric follicular lymphoma

Follicular lymphoma (FL) is the most common type of B cell non-Hodgkin lymphoma in Western counties. FL is usually seen in adults and is very uncommon in pediatric population. Pediatric follicular lymphoma (PFL) is a rare indolent lymphoma characteristically seen in pediatric population, usually involving cervical lymph nodes, Waldeyer ring, and testis. They pose significant diagnostic challenges due to morphologic overlap with much more common florid follicular hyperplasia and lack of typical t(14;18)IgH/BCL2 fusion and BCL-2 protein expression. We present the case of a 10-year-old male with bilateral conjunctival nodules, showing characteristic morphologic and immunophenotypic features of PFL with demonstrated clonal B cell immunoglobulin heavy chain gene rearrangement. Of note, the neoplastic cells expressed MUM1, MYC, and IgM, suggestive of a different disease pathogenesis from adult FL.