N. Emrah Koçer

Cutaneous Undifferentiated Small (Merkel) Cell Carcinoma, that Developed Synchronously with Multiple Actinic Keratoses, Squamous Cell Carcinomas and Basal Cell Carcinoma

Merkel Cell Carcinoma (MCC) is an uncommon undifferentiated neuroendocrine tumor, arising in skin mainly on sun‐exposed areas. We present an unusual case of primary cutaneous undifferentiated small cell carcinoma that co‐existed with six other lesions; 2 actinic keratoses, 3 squmaous‐cell carcinomas and a basal‐cell carcinoma. HE stained sections revealed MCC located in the mid‐dermis, co‐existing with severe actinic keratosis. Immunohistochemically, the tumor cells reacted to cytokeratin 20, epithelial membrane antigen, chromogranin and neuron specific enolase. This is an unusual case of cutaneous MCC co‐existing with six other different lesions. The concurrent development of MCC, squamous‐cell and basal‐cell carcinoma in the same patient indicates the pluripotent epidermal stem cell origin of these tumors. Further research is needed to enlighten the factors inducing this divergent differentiation.

Diagnostic utility of cytokeratin 19 expression in multinodular goiter with papillary areas and papillary carcinoma of thyroid

The most common benign lesion of thyroid, multinodular goiter, may mimic papillary carcinoma if it contains papillary areas. Although it is usually not very difficult to distinguish between these benign and malignant lesions, some cases may be problematic in differential diagnosis. In these cases, we decided to use cytokeratin 19 (CK 19), which is shown to be effective in discriminating papillary carcinoma from follicular carcinoma of thyroid, and we also evaluated the immunoreactivity of CK19 in follicular adenomas. Twenty-five cases of multinodular goiter showing papillary formations, 25 cases of papillary thyroid carcinoma, and 15 cases of follicular adenoma were selected from archives of our institution. Immunohistochemical staining for CK19 was performed on deparaffinized sections. Diffuse and intense CK19 positivity was found in the cells of all papillary carcinomas. In the multinodular goiter group, 20 of 25 cases showed no staining while the remaining 5 were focally reactive with CK19. Three of the five were thought to be false positive owing to hemorrhage. Weak and focal CK19 staining was seen in some follicular adenomas. Our observations suggest that the staining features of CK19 may be helpful in differential diagnosis between papillary carcinoma and multinodular goiter showing papillary areas. Focal and pale staining for CK 19 may be seen in multinodular goiter with papillary formations, and this feature should be considered in evaluation.

Cutaneous Involvement in Hodgkin's Lymphoma : Report of Two Cases

Hodgkins lymphoma (HL) comprises 20 to 30% of all lymphomas. Skin involvement is almost always secondary to visceral or nodal involvement. Secondary cutaneous HL is rare, occurring in only 0.5 to 3.4% of the cases. Herein we report two cases of skin involvement in Hodgkins disease. One was a 25‐year‐old female admitted with a draining sinus in the neck. The other was a 19‐year‐old female admitted with a neck mass and skin papules on her chest and arm. Skin involvement may antecede or can be seen during the course of HL. Better understanding of such cutaneous involvement, which occasionally may be the initial sign of HL, is needed, and a biopsy of any suspicious skin lesion should be considered.

The role of cytokeratin 19 in the differential diagnosis of true papillary carcinoma of thyroid and papillary carcinoma-like changes in Graves' disease.

Graves’ disease is an autoimmune disease predominantly seen in females. All types of thyroid cancers may co-exist with Graves’ disease but papillary carcinoma is the most frequent. Vesicular nuclei, nuclear grooves, and papillary formations that may be seen in Graves’ disease may lead the pathologist to an overdiagnosis of papillary carcinoma. The differential diagnosis between a true papillary carcinoma and foci mimicking papillary carcinoma in Graves’ disease may be challenging by light microscopic features only. This study is designed to determine whether CK19 is effective in the discrimination between the true papillary carcinoma of thyroid and foci resembling papillary carcinoma in Graves’ disease. Twenty-five cases with papillary carcinoma and 25 cases with Graves’ disease containing foci resembling papillary carcinoma were included in the study. All 25 cases with papillary carcinoma stained positive with CK19, whereas only six of 25 cases with Graves’ disease showed weak staining, and the remaining 19 cases were completely negative. It is known that CK19 may show faint staining in benign thyroid lesions such as adenomas. Staining pattern with CK19 together with histopathological findings may be helpful in the differential diagnosis between foci mimicking papillary carcinoma and true papillary carcinoma in Graves’ disease.

Histological features in routine tonsillectomy specimens: the presence and the proportion of mesenchymal tissues and seromucinous glands

Tonsillectomy is a frequently performed operation but there is little information about the histological features of a tonsillectomy specimen. In this study, we re-evaluated archival materials of 1220 cases who underwent tonsillectomy because of hyperplastic tonsils. Haematoxylin and eosin sections of the cases were re-examined and the presence and the proportion of mesenchymal tissues (skeletal muscle, cartilage, fat, bone) and seromucinous glands were noted as focal, multifocal or abundant. The incidence of skeletal muscle was 89 per cent (1085 cases; 206 focal, 465 multifocal, 414 abundant), seromucinous glands 35 per cent (429 cases; 236 focal, 134 multifocal, 59 abundant), fat 21 per cent (251 cases; 208 focal, 43 multifocal), cartilage three per cent (31 cases), and bone one per cent (seven cases). Also in 165 cases (14 per cent) skeletal muscle, in 12 cases (one per cent) was seromucinous glands, in eight cases (one per cent) was cartilage, in seven cases (one per cent) fat, and in four cases (less than one per cent) bone were found between hyperplastic lymphoid tissue. It can be concluded that mesenchymal tissues (skeletal muscle, cartilage, fat, bone) and seromucinous glands may be seen in different proportions in routine tonsillectomy specimens.

Diagnostic Accuracy of Toluidine Blue–Stained Wet Films in Effusion Cytology

OBJECTIVE To evaluate the usefulness of toluidine blue-stained wet films in the preliminary cytologic evaluation of serous effusions by means of specificity, sensitivity, and positive and negative predictive value. STUDY DESIGN One hundred seventy-six samples consisting of 122 pleural and pericardial effusions and 54 peritoneal effusions from 160 patients were included in the study. A toluidine blue-stained wet film of each sample was evaluated, and diagnoses were compared with the diagnoses by conventional smears and cell blocks on the same sample. RESULTS The sensitivity of wet films was 69%, 68% in pleural and pericardial effusions and peritoneal effusions, respectively, and the specificity of wet films was 93%, 92% in pleural and pericardial effusions and peritoneal effusions, respectively. Positive predictive values of smears alone were 78% and 75%; negative predictive values of smears alone were 96% and 95% in pleural and pericardial effusions and peritoneal effusions, respectively. CONCLUSION Preliminary cytologic evaluation of serous effusions with toluidine blue-stained wet films is simple and economical. It provides the opportunity to plan additional procedures for the samples.

Cost-Effectiveness of the Histopathologic Assessment of Tonsillectomy Material

Objective: To find out the significance of the histopathologic assessment of tonsillectomy materials in an attempt to understand the cost-effectiveness of this procedure. Patients and Methods: Hematoxylin- and eosin-stained sections of 1,820 tonsillectomy samples were re-evaluated, and clinical charts of the patients were made. Results: There was Actinomyces in 122 (6.7%), cryptic abscess in 144 (7.9%), cyst formation in 146 (8.0%) and granuloma in 11 (0.6%). Malignancy was found in 9 (0.5%) of 1,820 patients. In these patients with histopathologically confirmed malignancy, tonsillectomy had been performed with a presumptive diagnosis of malignant disease. Conclusions: Routine histopathologic examination of tonsillectomy material is not necessary unless there is a strong suspicion of malignancy on clinical evaluation. Thus, the cost of hospital expenses can be decreased to some extent. This will also eliminate the waste of time due to histopathologic assessment unless residency training is the subject of discussion. The medical-legal limitations should also be taken into consideration while making decisions about the necessity of histopathologic examination of these specimens.