Nasuhi Engin Aydin

A previously healthy 40 year-old-man with a recent shortness of breath and bilateral hilar based hazy opacities infiltrations of the lungs on radiology was submitted to a VATS biopsy for differential diagnosis. Microscopic sections of the lung biopsy showed granular eosinophilic acellular, alveolar consolidations with unremarkable alveolar walls. These alveolar secretions were strongly periodic acid-Schiff reaction with diastase (PAS-D) positive revealing their proteinaceous nature distinguishing them from simple transudates (i.e., edematous or inflammatory). This typical diffuse positive reaction with PAS staining is due to accumulation of large amounts of surfactant apoprotein. Methanamine silver stain was negative ruling out Pneumocystis jirovecii and fungal organisms. The patient was diagnosed as having alveolar proteinosis both clinically and pathologically. Although the diagnosis can be made by bronchoalveolar lavage (BAL) yielding a milky fluid, this condition may also be accompanied by tuberculosis, acute silicosis, nickel exposure, and other diseases so having a lung biopsy is beneficial in eliminating additional conditions.

Hydatid disease (cystic echinococcosis), is a parasitic disease caused by the intermediate stage of echinococcus granulosus in humans. The adult parasite is a small tapeworm living in the intestines of canidae. The dog-sheep cycle besides pastured cattle is important in many geographic areas. Hundreds of surgical operations to remove hydatid cysts and related complications take place in each year. Cysts occur mostly in the liver and lungs, and are usually less than 10 cm in diameter when clinically diagnosed but can attain larger sizes. Rupture and spillage of cyst fluid during surgery or trauma are important. If the hydatid cyst content has viable protoscolices (about 50% among resected surgical cases in our region), these structures result in numerous new cysts in the spillage area, besides a risk of anaphylaxis to the cyst fluid. Hydatid cysts in humans have a thick acellular laminated membrane with a tiny inner germinative layer yielding protoscolices which helps to distinguish it from other cestode cysts. A related parasite, echinoccus multilocularis (alveolaris) lesions mimic malignancy with invasive minute cysts without germinative layer and protoscolices in humans. Another cystic tissue parasite of humans, cysticercosis shows minute cysts (commonly less than 2 cm) with a larval form in each. Hydatid cysts may loose their germinative layer and protocolices in time, however, a periodic acid-Schiff (PAS) stain may reveal the thick laminated membrane of the parasite differentiating it from an epithelial cyst or amebic abscess readily.

A recently growing pink cutaneous nodule of the lower extremity in a three-year-old Caucasian girl was excised totally with a clinical presumptive diagnosis of “growing granulation tissue of undefined etiology”. The microscopic sections yielded highly characteristic features of a benign Spitz nevus of childhood. A highly cellular spindle cell lesion, without melanin pigmentation and prominent atypia, was noticed. Spitz nevi are distinctive melanocytic lesions of children (being rare in adults) with alarming cellular morphology to the unwary. These lesions are mainly symmetrical dermal and junctional (i.e. compound) nevi with epithelioid and spindle melanocytes having large nuclei with prominent nucleoli. The most important microscopic features are; symmetrical scanning power view, sharp demarcation, uniform maturation (zonation), epidermal hyperplasia, no high-grade atypia, few mitoses, no mitoses in deeper parts, and no subcutaneous tissue involvement. Some Spitzoid lesions present atypia and are, therefore, referred to as “atypical Spitz nevi” or “atypical Spitz tumors”. Also, there are rare malignant cases labeled as “Spitzoid melanoma” with microscopic similarities to these lesions mostly occurring in adulthood with epitheliod cells predominating rather than spindled cells. It is also important in difficult lesions to ask for a second opinion from expert dermatopathologists when indicated.

Odontojenik kistler yaygın görülmesine rağmen, aynı hastada iki farklı ve eş zamanlı odontojenik lezyonun oluşumu oldukça nadirdir. Daha önce, keratokisitk odontojenik tümörün adenomatoid odontojenik tümör, ameloblastoma, dev hücreli granulom, travmatik kemik kisti, palatal pleomorfik adenoma gibi çeşitli odontojenik ve non-odontojenik lezyonlarla beraber eş zamanlı oluşumu tanımlanmıştır. Ayrıca radiküler kist ile beraber mukoepidermoid karsinomu bulunan bir olgu da rapor edilmiştir. Literatürde, eş zamanlı keratokistik odontojenik tümör ve radiküler kistin eş zamanlı olarak ortaya çıktığı benzer bir vaka daha önce bildirilmemiştir. Bu olgu sunumunda, 26 yaşında bir erkeğin mandibula posterior bölgesinde radiküler kist ve keratokistik odontojenik tümörün eş zamanlı oluşumu gibi nadir bir durum sunulmaktadır.

A 40-year-old man presenting with headache and dizziness of several months duration was found to have a large intra ventricular mass during the clinical workup (Figure 1). A stereotactic biopsy of the mass revealed cellular neoplastic tissue with monotonous round cells (Figure 2). There was not any mitotic activity, necrosis, pleomorphism, micro vascular proliferation (Figure 3). Immuno his to chemical staining revealed negative staining with leucocyte common antigen (LCA) (Figure 4) and glial fibrillarey acidic protein (GFAP) (Figure 5) in the neo plastic cells. However there was diffuse and strong synaptophysin positivity (Figure 6). These pathologic findings pointed to a central Neurocytoma (CN) as outlined in the recent monograph of World Health Organization.

Fascioliasis is a rarely encountered parasitic infection in Turkey that mainly affects the liver and bile ducts. Other defined localizations of the parasite are the lungs, gastrointestinal system, and subcutaneous fatty tissue. Two cases of female patients who presented to the hospital with abdominal pain and whose physical examination and laboratory findings were normal except peripheral eosinophilia, were detected to have liver masses with necrotic areas. Segmental hepatectomies were performed in both cases with the preliminary diagnosis of liver tumors. Upon microscopic examinations of the resection materials, necrotic granulomatous inflammation with eosinophilic reaction at the periphery and the parasite (Fasciola hepatica) were seen. Both cases were reported to be fascioliasis according to these findings. Two cases of fascioliasis mimicking malignancy in the liver are presented here together with literature findings.

  Özet Amaç: Pleomerfik adenomlar tükrük bezlerinin benign tümörleridir. Duktal ve myoepitelyal hücrelerin karışımından köken alırlar. Bu neoplasmlar farklı histolojik çeşitliliğe sahip olduklarından miks tümör olarak adlandırılırlar. Pleomorfik adenomlar bütün tükrük bezi tümörleri arasında en sık rastlanılan tümör çeşididir. Bu raporda klinik ve histopatolojik özellikleri pleomrfik adenomayı gösteren 3 olguyu sunmayı amaçladık. Olgular: Olgu 1: 29 yaşındaki bayan hasta sert damağının sol tarafında bulunan şişlik şikayetiyle İnönü Üniversitesi Diş hekimliği Fakültesi Ağız Diş Çene Cerrahisi Anabilim Dalına başvurdu. Hastanın muayenesinde kitlenin, asemptomatik, yavaş büyüyen, nonülsere, 4.0-3.0 cm çapında olduğu görüldü. İnsizyonel biyopsi sonucu kitleye pleomorfik adenom tanısı kondu. Lokal anestezi altında kitle sağlıklı dokularıda içine alacak şekilde eksize edildi. Histopatolojik olarak pleomorfik adenom teşhisi konulan hastanın 1 yıl takibinde rekürrens tespit edilmedi. Olgu 2: 61 yaşındaki bayan hasta sol üst labial sulkusundaki şişlik nedeniyle İnönü Üniversitesi Diş hekimliği Fakültesi Ağız Diş Çene Cerrahisi Anabilim Dalına başvurdu. İnsizyonel biyopsi sonucu kitleye pleomorfik adenom tanısı kondu. Lokal anestezi altında kitle diseke edilip çıkarıldı. 1 yıllık takip süresi sonrası rekürrens gözlenmedi. Olgu 3: 48 yaşındaki erkek hasta İnönü Üniversitesi Diş hekimliği Fakültesi Ağız Diş Çene Cerrahisi Anabilim Dalına diş çekimi için başvurdu. Yapılan klinik muayenede sert damaktaki şişlik fark edildi. İnsizyonel biyopsi sonucu kitleye pleomorfik adenom tanısı kondu. Genel anestezi altında kitle eksize edildi.1 yıllık takip süresi sonunda rekürrens gözlenmedi. Sonuç: Minör tükrük bezlerinde görülen pleomorfik adenomların tedavisi geniş lokal eksizyonla kitlenin çıkarılmasıdır. Enükleasyon yüksek rekürrens oranından dolayı tavsiye edilmemektedir. Malign dönüşüm riski ve ilk eksizyondan uzun yıllar sonra bile rekkürrens görülme ihtimali olduğu için erken teşhis, tedavi ve uzun takip periyodu pleomorfik adenom olgularında önemlidir. Anahtar Kelimeler: Pleomorfik adenom, Sert damak, Dudak Abstract Aim: Pleomorphic adenomas are benign tumors of salivary glands that are derived from a mixture of ductal and myoepithelial cells. Because of their remarkable histological diversity, these neoplasms have also been called mixed tumors. Among all salivary gland tumors pleomorphic adenoma is the most common tumor. In this study we aimed to present clinical and histopathological features of 3 cases diagnosed as a Pleomorphic adenoma. Cases: Case1: A 29-year-old female patient was referred to the İnönü University Faculty of Dentistry Maxillofacial Surgery Department with the chief complaint of a swelling in the left side of the hard palate. On physical examination, a mass was palpated and it was asymptomatic, slow-growing, non-ulsere submucosal nodule with diameter 4.0–3.0 cm. An incisional biopsy was performed and under local anesthesia the mass was dissected and removed.. After 1 year follow-up there was no evidence of recurrence Case2: A 61 year old female patient was referred to the İnönü University Faculty of Dentistry Maxillofacial Surgery Department with a history of a painless lump in her upper left labial sulcus. After incisonal biopsy pleomorfic adenoma was diagnosed. Under local anesthesia the mass was dissected and removed. After 1 year follow-up there was no evidence of recurrence. Case3: A 48-year-old male patient was referred to the İnönü University Faculty of Dentistry Maxillofacial Surgery Department for tooth extraction. On clinical examination a painless lump was detected in his hard palate. After incisonal biopsy pleomorfic adenoma was diagnosed. Under general anesthesia the mass dissected and removed. After 1 year follow-up there was no evidence of recurrence. Result: The treatment of pleomorphic adenoma in minor salivary gland is wide local excision. Enucleation alone is not advisable because of the high rate of recurrence. Early diagnosis, treatment and long-term follow-up of PA are important because of the risk of malignant transformation and high risk of recurrence even several years after first excision. Key Words: Pleomorphic Adenoma; Hard Palate, Lip