Merih Tepeoglu

Conventional transbronchial needle aspiration: From acquisition to precision

Introduction: Conventional transbronchial needle aspiration (C-TBNA) is a minimally invasive, safe, and cost-effective technique in evaluating mediastinal lymphadenopathy. Previously we reported that the skills for C-TBNA can be acquired from the books. We studied the learning curve for C-TBNA for a single bronchoscopist at a tertiary-care center where ultrasound technology remains difficult to acquire . Methods: We prospectively collected results of the first 99 consecutively performed C-TBNA between December 2009 and 2013. Patients were divided into 3 groups: (I): First 33, (II): Next 33 and (III): Last 33. Results were categorized as malignant, non-malignant or non-diagnostic. Diagnostic yield (DY), sensitivity (SEN), specificity (SPE), positive and negative predictive values (PPV, NPV), and accuracy (ACC) were calculated to learn the learning curve for C-TBNA. Results: Total 99 patients (M:F = 62:37), mean age 58.2 ± 11.5 years, mean LN diameter 26.9 ± 9.8 mm underwent C-TBNA. Sixty-nine patients had lymph nodes (LNs) >20 mm in diameter. Final diagnoses were established by C-TBNA in 44 (yield 44.4%), mediastinoscopy 47, transthoracic needle aspiration 5, endobronchial biopsy 2 and peripheral LN biopsy 1. C-TBNA was exclusively diagnostic in 35.4%. Group I: DY: 42.4%, 64.7% in malignancies, 19% in benign conditions (P = 0.008). SEN, SPE, PPV, NPV, ACC = 70%, 100%, 100%, 66.6%, 78.7%, respectively. Group II: DY: 54.5% (36.4% exclusive), 88.2% in malignancies and 19% benign conditions (P = 0.000). SEN, SPE, PPV, NPV, ACC=72%, 100%, 100%, 53.3%, 78.7%, respectively. Group III: DY: 36.3% (27% exclusive), 100% in malignancies and 16% in benign conditions. SEN, SPE, PPV, NPV, ACC = 92.3%, 100%, 100%, 95.2%, 97%, respectively. No difference was found in relation to LN size or location and TBNA yield. Conclusion: C-TBNA can be easily learned and the proficiency can be attained with <66 procedures. In selected patients, its exclusivity could exceed 35%.

Ovarian Serous Borderline Tumor Detected by Conventional Papanicolaou Smear: A Case Report

Background: Although the Papanicolaou (Pap) smear was originally designed to detect premalignant cervical lesions and cancer, it has become apparent that malignant cells from extrauterine primaries may also appear in the smears. Here, we report a case of a serous borderline tumor (SBT) of the ovary that was detected by a conventional Pap smear. Case Report: In a 34-year-old woman, who was operated on for a left borderline ovarian tumor 2 years ago, glandular dysplasia was discovered in a Pap smear screening. The Pap smear showed a large number of atypical glandular cells forming 3-dimensional papillary clusters. The cell clusters were enlarged and had variably sized round or oval nuclei. The background was clean, and this finding pointed to the noncervical origin of the malignant cells. A right ovarian cystic mass was discovered and a laparotomy performed. A histologic examination of the ovarian mass revealed a SBT of the ovary. Conclusion: This case illustrates the value of the Pap smear in discovering unsuspected extrauterine malignancies, including SBTs of the ovary.

Peritoneal washing cytology in an adult granulosa cell tumor: A case report and review of literature

Adult-type granulosa cell tumors (AGCT) account for 1-2% of all ovarian tumors and 95% of granulosa cell tumors. In AGCT, at the time of peritoneal washing, tumor cells are rarely seen to exfoliate and FIGO stage is raised from IA/IB or IIA/IIB to stage IC or IIC despite the absence of a gross intraepithelial tumor. Patients with positive peritoneal washing cytology must be followed up for pelvic recurrence and metastasis. A more sensitive cytologic evaluation, histopathologic correlation and immunohistochemical staining can advance our practice. Here, we describe a case of AGCT with the emphasis on cytologic features observed in specimens obtained from peritoneal washing fluid.

An unusual eyelid mass: Tarsal dermoid cyst

We report the case of a 15-month-old boy who presented with a mass lesion of the right upper eyelid that had been present since birth and had slowly enlarged over the last 3 months. The lesion had minimal surrounding erythema simulating the appearance of a chalazion. Intraoperatively the lesion was noted to be firmly adherent to the underlying tarsus. The lesion was excised completely through an eyelid crease approach leaving the tarsus intact. The histopathology was consistent with dermoid cyst. To our knowledge, this is the third case of a tarsal dermoid cyst reported in the literature. Dermoid cyst should be included in the differential diagnosis of eyelid mass lesions, and particulary differentiated from a chalazion to avoid mismanagement that may lead to scarring, recurrence and inflammation. The excision of these lesions sparing the underlying tarsus can be possible.

Biphasic Pulmonary Blastoma Associated with Cerebral Metastasis.

Pulmonary blastoma is a very rare malignant tumor of the lungs. A biphasic pulmonary blastoma was histologically diagnosed by a characteristic finding as it was mainly constituted of immature tumor tissue that had both epithelial and mesenchymal components. We present a case of a 68-year-old man with biphasic pulmonary blastoma. The patient underwent cranial metastatectomy and left lung upper lobectomy. Although the tumor was resected, there was rapid metastasis to the cranial, liver, kidney and multiple bones. Although radiotherapy and chemotherapy were administrated, the patient died about 6 months postoperatively. Close follow-up and aggressive chemotherapy should be considered for such tumours. In the light of this case, the authors review the pathologic, clinical, radiological and therapeutic features of this very rare malignant lung tumor.

Lung Malignancy in Solid Organ Transplant Recipients: A Case Series

Introduction Transplant recipients are at a higher risk for developing malignancies when compared to general population. These malignancies can be transmitted by a donor organ, can be related to the recipients’ past history of a cancer which relapses or develops de novo as a result of extensive immunosuppressive drug regimens. We aim to characterize the transplant recipients who were diagnosed with a lung malignancy over the past 10 years. Materials and Methods Medical records of solid organ transplant (SOT) recipients from January 2007 to November 2017, who presented with lung malignancies to our clinic were reviewed retrospectively. Results For the last 10 years a total of 6 SOT recipients (5 male and 1 female) with an average age of 58.6 ± 7.4 years were identified to have been diagnosed with a lung malignancy. Within these patients 4 had a liver transplant, 1 had kidney and 1 had a heart transplant history. 3 of the liver recipients had a history of hepatocellular carcinoma (HCC) and 1 patient with cholangiocellular carcinoma before transplantation, whereas the kidney and heart transplant patients had no history of cancer. Half of the patients were smokers. The median time from the transplantation to the diagnosis of lung cancer was measured as 12.5 months. 3 of the liver transplant patients who presented with multiple metastatic lesions in lung were diagnosed with metastatic carcinoma upon pathological examination of transbronchial biopsy and lobectomy material. 1 liver transplant patient who was also a heavy smoker had a diagnosis of squamous cell carcinoma 12 years post-transplant. 2 of the liver transplant patients had also acute rejection diagnosed upon liver biopsy at the same time as cancer detection. The renal transplant patient, also a smoker, had a diagnosis of small cell carcinoma, extended type with liver and bone metastasis, whereas the heart transplant patient was diagnosed with a low grade differentiated neuroendocrine type of cancer. 2 of the patients died. Discussion The incidence of lung cancer is shown to be especially increased in heart and lung transplant patients and related to smoking. However the incidence is also increased following other SOTS. When compared to the general population the increased incidence of lung malignancy was found to be similar to those diagnosed with HIV which reflects the critical role that chronic and prolonged immunosuppression has on lung. In our series 3 metastatic carcinomas of the primary tumor were identified pretransplant, 2 primary lung cancers related to heavy smoking and one case without previous cancer or smoking history were presented. Even though the number is low the variety shows that multiple mechanisms are responsible for increased cancer incidence in transplant patients. Conclusion Transplant patients, regardless of previous malignancy history or risk factors, should all be closely monitored life-long with periodic screening examinations for early malignancy detection.

Human papilloma virus (HPV) negatif verrusiform ksantom: Skrotumda nadir görülen benign tümör

Verrusiform ksantom oldukca nadir gorulen ve genellikle oral mukozayi tutan benign bir neoplazidir. Mukoza disinda az sayida vaka ile vulva, skrotum, penis, anal bolge ve ekstremitelerde yerlestigi bildirilmistir. Makroskopik gorunumu nedeniyle klinik olarak kondiloma akuminatum, verrukoz karsinom ve skuamoz hucreli karsinom ile karisabilir. Ayirici tani icin mutlaka lezyonun eksizyonu ve histopatolojik incelemesi gereklidir. Bu lezyonun etyopatogenezi hala tartismalidir. Literaturde HPV enfeksiyonu pozitif vakalar bildirilmistir. Ancak HPV ile iliskisi net aciklanamamistir. Bu yazida, skrotumda yerlesim gosteren bir verrusiform ksantom olgusunu, nadir gorulmesi, HPV negatif olmasi ve klinik olarak malignite ile karismasi sebebiyle sunmayi amacladik.

Cloacogenic adenocarcinoma of the vulva: a case report and review of the literature

Primary adenocarcinoma of the vulva, unrelated to the native glands of perineum is an extremely rare neoplasm. Despite awareness of this lesion for over 40 years, the origin is not beyond speculation. The most reasonable hypothesis is based on the remnants of cloacal differentiation during early days of life. Here we report the case of a 60-year-old patient with a vulvar mass, who underwent partial vulvectomy and bilateral regional lymph node dissection. The tumor was composed of papillary and complex glandular structures and exhibited diffuse positivity for cytokeratin 20 and polyclonal CEA, CDX2, and focal positivity with cytokeratin 7. Unlike the indolent behavior of this malignant neoplasm according to the literature, we found two metastatic inguinal lymph nodes. She did not receive adjuvant therapy and is still alive, free of disease 38 months after surgery. We present different aspects of vulvar adenocarcinomas with a case report.

Chest wall implantation metastasis caused by percutaneous radiofrequency ablation for hepatic tumor.

We report a very rare case of a 55-year-old man with chest wall metastatic tumor caused by seeding of hepatocellular carcinoma after percutaneous radiofrequency ablation (RFA) for hepatic tumor 42 months after the initial operation. The patient was managed with aggressive full-thickness chest wall resection and reconstruction with a Prolene (Ethicon, Somerville, NJ) and methyl methacrylate sandwich graft and subsequent musculocutaneous free-flap transposition.

Chondromyxoid Fibroma of the Sternum in a 63-Year-Old Woman

Primary chondromyxoid fibroma is a benign bone tumor. Its localization in the sternum is quite rare; we found only 6 relevant reports. We report our diagnosis and treatment of a chondromyxoid fibroma in the sternum of a 63-year-old woman. The patient underwent subtotal sternectomy and chest-wall reconstruction with use of a titanium rib bridge system and Prolene mesh. The patients clinical course was uneventful, and she had no local recurrence 41 months postoperatively. Our review herein of the 6 previous cases reveals that our patient is the oldest thus far to have been diagnosed with a sternal chondromyxoid fibroma.