Junu Ojha

Lymphoepithelioma-like carcinoma of head and neck skin: a systematic analysis of 11 cases and review of literature

Lymphoepithelioma-like carcinoma of the skin (LELCS) is a rare tumor of unknown etiology, low malignant potential, and microscopic resemblance to undifferentiated nasopharyngeal carcinoma. Clinically, it presents as a flesh-colored firm nodule or plaque on the face, scalp, or shoulder of middle-aged to elderly individuals. Histologically, LELCS is composed of islands of enlarged epithelial cells with large vesicular nuclei surrounded and permeated by a dense lymphoplasmacytic infiltrate. LELCS exhibits immunoreactivity with high-molecular-weight cytokeratins and epithelial membrane antigen, indicating the epithelial origin. The differential diagnosis includes basal cell carcinoma, squamous cell carcinoma, lymphoma, pseudolymphoma, and Merkel cell carcinoma. We report 11 cases of LELCS of the head and neck region with discussion of the clinical, histopathologic, immunohistochemical, and therapeutic aspects of this rare cutaneous neoplasm. In addition, we systematically review and compare the findings with the previously published cases of LELCS. This study is the largest case series of LELCS reported in the English-language literature. It attempts to more clearly define the diagnostic criteria for LELCS. Its histomorphologic and immunophenotypic features help distinguish this tumor from similar-appearing malignancies, including metastatic nasopharyngeal carcinoma.

Post-transplant lymphoproliferative disorders of oral cavity

Post-transplant lymphoproliferative disorders (PTLD) are long-term complications of immunosuppression after solid organ/bone marrow transplantation. In most cases, PTLD arises as a result of primary or reactivated Epstein-Barr virus infection in a host with impaired cellular immunity. PTLD is most often seen in the gastrointestinal tract, although it has also been reported in other organ systems, including the central nervous system and, rarely, in the head and neck. It is characterized histologically by abnormal lymphoid cell proliferation. Although many forms of PTLD do not meet all of the histologic criteria of lymphoma, they often behave clinically in a malignant fashion if left untreated. We present 3 rare cases of PTLD manifesting in the oral cavity as mucosal masses after solid organ transplantation. There are only 8 published reports of PTLD in the literature presenting as oral lesions. The clinical, pathologic, and therapeutic spectra of PTLD are discussed.

Labial salivary gland biopsies in Sjögren's syndrome: still the gold standard?

OBJECTIVES The accuracy and diagnostic benefits of the labial salivary gland (LSG) biopsy for Sjögrens syndrome (SS) have received mixed reviews. This study was conducted to assess (1) the inter-rater agreement among 5 pathologists, and (2) the relationship between biopsy findings and clinical disease parameters. STUDY DESIGN Three oral pathologists (OP) and two surgical pathologists (SP) provided independent diagnoses, focus scores, and plasma cell characterizations for 37 LSG biopsies. Inter-rater reliability was assessed using percentage of overall agreement and intraclass correlation coefficients. Relationships between diagnoses and clinical parameters were assessed by nonparametric correlations. RESULTS Overall agreement among the pathologists was poor, although the intra-specialty agreement was good. The ratings of OP were most highly correlated with serological measures, while those of SP were correlated with salivary flow rate and disease damage. CONCLUSION Since the LSG biopsy can be the determining factor in SS diagnoses, these demonstrated inconsistencies merit further consideration.

Hereditary Paraganglioma of the Nasopharynx

Head and neck paragangliomas are rare neuroendocrine tumors derived from neural crest cells of parasympathetic ganglia or the widely dispersed neuroendocrine cells of the head and neck region. Paragangliomas of the sinonasal tract and nasopharynx are rare. The clinicopathologic features of this unique example of a hereditary, nasopharyngeal paraganglioma, and selective entities that are included in its differential diagnosis are presented.

A large radiolucent lesion of the posterior maxilla

CASE PRESENTATION A 47-year-old woman presented to the oral and maxillofacial surgeon by referral from her general dentist for evaluation and management of a slightly mobile vital tooth #15, which exhibited mild sensitivity to percussion. The patient vaguely recalled episodes of dull, intermittent pain in the area a few months prior. A bitewing taken at the referring dentist’s office did not demonstrate any evidence of dental decay but suggested the presence of bone loss distal to the tooth, with a 6-mm probing depth distal to the tooth (Fig. 1). According to the referring dentist, a panoramic radiograph, which could not be retrieved for review, demonstrated the presence of pronounced bone loss distal to tooth #15. The patient denied any significant medical, surgical or social history, including tobacco, alcohol, or illicit substance abuse. She was not taking any prescription medications. Extraoral head and neck examination was unremarkable. There was no evidence of lymphadenopathy or any abnormal masses or rashes. Similarly, the thyroid gland appeared supple and nonpalpable. Intraoral examination revealed a slightly mobile asymptomatic tooth #15. The remainder of her oral soft tissue examination was unremarkable.

Colloid milium of the oral cavity: a rare presentation

Colloid milium (CM) is a rare condition characterized by the presence of multiple dome-shaped amber- or flesh-colored papules developing on sun-exposed skin. It is a degenerative condition linked to excessive sun exposure and possibly exposure to petroleum products and hydroquinone. The origin of the colloid deposition in the dermis is uncertain, although it is thought to be due to degeneration of elastic fibers. The condition is rare, with only 100 case reports documented in the world literature. The most commonly involved sites are the face, periorbital region, backs of the hands, back and sides of the neck, and ears. Involvement of the oral cavity is extremely rare. The purpose of this article is to report an extremely rare first case of CM of the oral cavity and to discuss the clinical, pathologic and therapeutic spectra of CM.

Intraoral Diffuse Large B-Cell Lymphoma With Burkitt-like Morphology in an HIV-Positive Patient-A Diagnostic Dilemma

c S c T q r m H o f C m ( m c [ p s s w t w I l p p e d g A s o m c c a t m d a p uman immunodeficiency virus (HIV) infection has een associated with a 60-fold increased risk of nonodgkin lymphoma (NHL) when compared with the eneral population. The vast majority of HIV-assoiated lymphomas are high-grade B-cell lymphomas, rimarily Burkitt lymphoma (BL), diffuse large B-cell ymphoma (DLBCL), lymphoma with plasmacytic diferentiation, and rarely the “primary effusion lymhoma” and “plasmablastic lymphoma” of the oral avity. Among these, BL and DLBCL are the 2 most ommon types of NHL seen in association with HIV nfection. These 2 entities possess many overlapping linical and microscopic features that make the estabishment of a precise diagnosis difficult especially in a etting where DLBCL displays Burkitt-like morpholgy, resembling Burkitt-like lymphoma (BLL), a reently described variant of BL. Although DLBCL with urkitt-like morphology does not fulfill strict criteria or a diagnosis of BL, it has certain histologic, immuophenotypic, and genetic features that overlap with eatures characteristic of BL. A correct diagnosis is rucial because they have different management and rognostic implications. DLBCL with BL-like morpholgy are considered aggressive and may require more ntensive therapy than what is usually considered adquate for DLBCL. We discuss the clinical, histomorphologic, immuophenotypic, genetic, and therapeutic features of LBCL in contrast to BLL and describe a rare case of LBCL with Burkitt-like morphology involving the

Original ContributionsDiagnostic ChallengeRecurrent pain and swelling associated with impacted maxillary third molar

A 57-year-old woman reporting intermittent severe pain and swelling for 5 years in the left maxillary jaw was evaluated at the oral and maxillofacial surgery clinic at the University of Detroit Mercy School of Dentistry. The pain intensity had increased markedly in the past 2 to 3months. She had difficulty swallowing and opening her mouth, and a bad odor associated with a bloody mucous discharge. Her medical and surgical history included chronic neck pain, arthritis, degenerative disk disease, choroid cyst, headaches associated with Arnold-Chiari malformation, sinus surgery due to recurrent sinusitis, and an eye surgery for strabismus. Her dental history included periodic pain and soreness associated with impacted tooth no. 16. Her health history included a 40 pack-year smoking history, and at the time of her examination she was smoking 1 pack per day. She denied alcohol or illicit drug use. Extraoral examination identified a nonerythematous, firm swelling on the left side of her face without evidence of lymphadenopathy. On the basis of the long-standing pain and swelling, the difficulty in opening, and the history of surgery in the left maxillary sinus, the decision was made to examine the patient with cone-beam computed tomography (CT). This technique permits a view of the anatomy in 3 planes of space. It also provides a larger field of view than panoramic radiographs, which was especially beneficial due to the unknown position of the left third molar. The cone-beam CT scan revealed diffuse opacification of the left maxillary sinus with destruction of the alveolar process and resorption of the walls of the maxillary sinus. The pathologic alterations extended beyond the field of view, and considering the likely involvement of extra-antral soft tissues it was decided that CT was necessary for complete radiographic visualization of the condition. A bone window axial view of the CT scan revealed the lesion in the left maxillary sinus associated with destruction of the anterior, posterior-lateral, and medial walls of the left maxillary sinus, with extension into the pterygopalatine fossa as well as the buccal and masticator spaces (Figure 1). Soft-tissue sections depicted infiltration of the lesion into the medial and lateral pterygoid muscles, and extension into the nasal fossa (Figure 2) and greater palatine foramen (Figure 3). Destruction of the palate and left maxillary alveolar ridge was also observed (Figure 4). Microscopic examination after an incisional biopsy revealed a proliferation of squamous epithelium. Cells exhibiting increased nuclear-cytoplasmic ratios, pleomorphism, individual cell keratinization, and increased mitotic activity were noted (Figure 5).

Recurrent pain and swelling associated with impacted maxillary third molar

A 57-year-old woman reporting intermittent severe pain and swelling for 5 years in the left maxillary jaw was evaluated at the oral and maxillofacial surgery clinic at the University of Detroit Mercy School of Dentistry. The pain intensity had increased markedly in the past 2 to 3months. She had difficulty swallowing and opening her mouth, and a bad odor associated with a bloody mucous discharge. Her medical and surgical history included chronic neck pain, arthritis, degenerative disk disease, choroid cyst, headaches associated with Arnold-Chiari malformation, sinus surgery due to recurrent sinusitis, and an eye surgery for strabismus. Her dental history included periodic pain and soreness associated with impacted tooth no. 16. Her health history included a 40 pack-year smoking history, and at the time of her examination she was smoking 1 pack per day. She denied alcohol or illicit drug use. Extraoral examination identified a nonerythematous, firm swelling on the left side of her face without evidence of lymphadenopathy. On the basis of the long-standing pain and swelling, the difficulty in opening, and the history of surgery in the left maxillary sinus, the decision was made to examine the patient with cone-beam computed tomography (CT). This technique permits a view of the anatomy in 3 planes of space. It also provides a larger field of view than panoramic radiographs, which was especially beneficial due to the unknown position of the left third molar. The cone-beam CT scan revealed diffuse opacification of the left maxillary sinus with destruction of the alveolar process and resorption of the walls of the maxillary sinus. The pathologic alterations extended beyond the field of view, and considering the likely involvement of extra-antral soft tissues it was decided that CT was necessary for complete radiographic visualization of the condition. A bone window axial view of the CT scan revealed the lesion in the left maxillary sinus associated with destruction of the anterior, posterior-lateral, and medial walls of the left maxillary sinus, with extension into the pterygopalatine fossa as well as the buccal and masticator spaces (Figure 1). Soft-tissue sections depicted infiltration of the lesion into the medial and lateral pterygoid muscles, and extension into the nasal fossa (Figure 2) and greater palatine foramen (Figure 3). Destruction of the palate and left maxillary alveolar ridge was also observed (Figure 4). Microscopic examination after an incisional biopsy revealed a proliferation of squamous epithelium. Cells exhibiting increased nuclear-cytoplasmic ratios, pleomorphism, individual cell keratinization, and increased mitotic activity were noted (Figure 5).

White lesion on the dorsum of tongue

A 57-year-old African American man presented to the oral and maxillofacial clinic at the University of Detroit Mercy School of Dentistry for evaluation of a white lesion of the tongue. The patient reported that the lesion first presented 2 years earlier with slight pain and had become asymptomatic over time. The patient also reported that he picked at the lesion several times and had previously removed portions of it. The lesion then grew back over a period of weeks. The patient’s medical history was unremarkable. He denied history of infectious or sexually transmitted diseases, allergies, medications, or trauma. The patient’s social history was positive for 40 pack-years of tobacco smoking. He also presented with significant history of marijuana and intravenous drug abuse. Extraoral examination did not reveal any abnormalities. There was no evidence of lymphadenopathy. There was no history of previous similar lesions elsewhere or any systemic complaints. Intraoral examination revealed a thickened, large, painless, white plaque measuring approximately 4 4 cm on the dorsum of the tongue. The lesion appeared to exhibit slightly tan to brownish discoloration most likely owing to extrinsic staining related to the patient history of cigarette smoking. The central portion of the lesion appeared to be markedly elevated, displaying a verrucous, nodulelike appearance. A small area in the center of the lesion appeared to be slightly erythematous. The bulk of the lesion was