Paul Norris

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.

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.

Trans-tracheostomy suction technique to reduce lower airways contamination from oropharyngeal secretions

olonization of the oropharynx and microaspiration of ecretions are causative factors for ventilator-associated neumonia1. Suctioning and airway management practices ay influence the development of ventilator-associated neumonia2. We routinely use a fenestrated tracheostomy tube with a on fenestrated inner tube for the first few post operative ays. Removal of the inner tube for toileting triggers a cough eflex. This suggests that oropharyngeal secretions collect on op of the tracheostomy tube and fall through the fenestrations nto the airways below when the non fenestrated inner tube s removed. We describe a maneuver to reduce the amount of secreion that can pass from the oropharynx to the lower respiratory ract. This involves the insertion of a flexible fine tip suction atheter (12 gauge) beyond the tracheostomy into the trachea, ith suctioning through the inner tube of the tracheostomy rior to its removal. Suction continues as the inner tube is emoved. The value of this technique and the capture of secreions can be easily demonstrated with a blue dye introduced nto the patient’s oral cavity and subsequently seen in the uction tube (Fig. 1).

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.

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.