Abstracts
P1. A CASE REPORT OF CARDIAC MYXOMA PRESENTING AS CEREBROVASCULAR EVENT
Awla Mohd Azraai¹, Noor Kaslina Mohd Kornain¹, Mardiana Abdul Aziz¹, Nor Salmah Bakar¹
¹Department of Pathology, Faculty of Medicine, Universiti Teknologi MARA, Sg Buloh Campus, 47000 Sg Buloh, Selangor, Malaysia
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Introduction:
Cardiac myxoma (CM) is the most common benign primary neoplasm of the heart; its aetiology is unknown. It usually occurs in the left atrium. Most cases are sporadic, occurring in middle-aged women. They usually present with mitral stenosis or insufficiency. Embolic phenomenon is occasionally seen. We present a case of an unsuspected ischaemic stroke due to CM emboli.
Clinical Case:
A 53-year-old woman with underlying Diabetes mellitus, hypertension and hyperlipidemia presented with sudden onset slurring of speech, facial asymmetry and right hemiparesis. She had no chest pain, breathlessness or heart failure. CT brain showed acute left frontal lobe infarct. A trans-esophageal echocardiogram revealed left atrial mass measuring 7.8cm x 2.1 cm. There was no abnormality of the valves, wall and septum. Other causes of stroke were ruled out clinically. She underwent a resection of the cardiac mass. The specimen was composed of multiple irregular pieces of firm, brown polypoid tissue measuring 70x40x20 in aggregate with heterogenous glistening surface. Microscopy demonstrated paucicellular myxoid material containing fusiform or stellate cells with elongated, ovoid nuclei. They were arranged in single or multiple layers surrounding vascular channels. Nuclear atypia and mitotic activity were absent. Hemosiderin-laden macrophages and scattered inflammatory cells were noted. Gamna-gandy bodies were absent. All these features are consistent with CM.
Discussion:
Neurological complications attributed to CM are seen in 20–35% of patients. The production of emboli is ascribed to the overexpression of matrix metalloproteinases. The tumour emboli are related to the mobility and friability of the mass rather than the tumour size. Surgical excision is curative however local recurrences have been reported. In conclusion, CM is a benign entity however its predisposition to emboli in 30 to 40% of cases may result in fatality. Patients may present in an atypical manner thus a multidisciplinary approach is crucial.
P2. A CASE SERIES OF HUMAN INTESTINAL SPIROCHAETOSIS: BRUSHING THE BRUSH BORDERS
Mardiana Abdul Aziz¹, Awla Mohd Azraai¹, Effat Omar¹², Nor Salmah Bakar¹
¹Department of Pathology & ²Institute of Pathology, Laboratory and Forensic Medicine (IPPerforM), Faculty of Medicine, Universiti Teknologi MARA, Sg Buloh Campus, 47000 Sg Buloh, Selangor, Malaysia.
Introduction:
Human intestinal spirochaetosis (IS) is an uncommon infection caused by non-treponemal spirochaetes Brachyspira aalborgi or Brachyspira pilosicoli. It may affect any part of the colorectum and its diagnosis relies on demonstration of the filamentous spirochaetes on the surface epithelium. We present three cases of IS, diagnosed with the aid of a simple panel of histochemical stains.
Clinical Case:
Case 1: A 65-year-old man presented with loss of appetite and passing blood and mucous per rectum (PR). Colonoscopy showed sigmoid colon diverticulitis and rectosigmoid ulceration. Case 2: A 63-year-old man with loss of appetite and 10kg of weight in 2 months. Colonoscopy found a sigmoid colon polyp. Case 3: A 22-year-old woman with PR bleeding for 3 months, loss of appetite and weight. Colonoscopy revealed inflamed ileo-caecal valve. Microscopic examination of all cases demonstrated coating of surface epithelium (in some areas) by an end-on-end attachment of basophilic, 3μm-thick filamentous spirochaetes, forming a false brush border. The organism was positive for PAS and Giemsa; whilst negative for Mucicarmine, providing a reliable discrimination from mucin. In cases 1 and 3, there was associated focal active inflammation, increased lymphoplasmacytic cells and mild architectural distortion. While in case 2, the spirochaetes colonized the surface of a hyperplastic polyp.
Discussion:
IS is more common in HIV-positive men; association with polyps, diverticular and inflammatory bowel diseases have been documented. Patients may be asymptomatic or present with diarrhoea, abdominal pain, or loss of appetite or weight; as in our cases. The false brush border should alert the observer of this entity. Diagnostic challenges include focality of microorganisms, paucity of inflammation, and confusion with mucin. Giemsa and Mucicarmine provide the best discriminatory staining pattern.
P3. AMNIOTIC FLUID EMBOLISM, RARE BUT HIGHLY CATASTROPHIC: A CASE REPORT
Fatin ‘Amira Mohamed Anwar¹, Noorasmaliza Md Paiman¹, Mazniza’in Mohammad²
Department of Pathology¹, Department of Obstetrics & Gynaecology², Hospital Sultanah Bahiyah, Alor Setar
Introduction:
Amniotic fluid embolism (AFE) is a rare, potentially fatal complication of pregnancy and an obstetric emergency. It is extremely difficult to anticipate and hence to prevent despite the precautions taken. It is a diagnosis of exclusion.
Clinical Case:
A 38-year-old Malay lady, at 39 weeks gestation of her second pregnancy (gravida 2, para 1), experienced spontaneous onset of contractions. Her pregnancy was complicated by one previous scar, advanced maternal age and anemia. She had a ventouse assisted delivery following fetal distress. The delivery was further complicated by primary post-partum hemorrhage secondary to intermittent uterine atony. Subsequently, she experienced a hypotensive episode with unrecordable blood pressure and was intubated promptly. Maternal bradycardia and asystole developed and cardiopulmonary resuscitation (CPR) was performed. The resulting haemorrhage and shock necessitated massive blood transfusion. Unfortunately, she died the following day. Autopsy was not performed but the husband agreed for bedside biopsy of the lung tissue. Histopathologic examination of the lung showed presence of fetal squames within the capillaries in addition to few thrombosed small vessels.
Discussion:
Amniotic fluid embolism is one of the feared and devastating complications of pregnancy. It can neither be foreseen nor prevented. The management is largely supportive and also the mortality of the condition remains high. A reliable diagnosis can often be made upon histological examination. However, it is nonspecific and remains limited and controversial.
P4. PRIMARY CUTANEOUS MUCINOUS CARCINOMA OF THE EYELID: A CASE REPORT
Fatin ‘Amira Mohamed Anwar, Haidi Mohamad
Department of Pathology, Hospital Sultanah Bahiyah, Alor Setar
Introduction:
Primary mucinous carcinoma is a rare, mucin-secreting skin adnexal neoplasm. The majority of these tumours arise on the face, with 30% on the eyelid and 43% elsewhere on the head and neck. Diagnostic dilemmas include its deceivingly benign look in some cases and also the problem in differentiating it from metastatic mucinous adenocarcinoma of particularly breast and gastrointestinal tract. This tumour is treated by wide local excision. Though this tumour has low metastatic potential, it does have a significant recurrence rate.
Clinical Case:
We present a case of primary mucinous adenocarcinoma of the eyelid in an 81-year-old Malay gentleman who presented with painless, right upper eyelid swelling for 1 year. On examination, there was a right upper eyelid mass with skin and tarsal involvement until lateral canthus. He underwent excision and upper eyelid reconstruction. Histopathologic examination revealed an infiltrative lesion composed of basaloid islands of tumour cells floating in large pools of mucin separated by fibrous septae. The tumour cells were seen infiltrating the adjacent skeletal muscle and involved margins. The tumour cells are cytokeratin 7 (CK7) positive and cytokeratin 20 (CK20) and CDX2 negative.
Discussion:
Due to its rarity, primary mucinous carcinoma of the eyelid poses diagnostic challenges to clinician and pathologist. It is almost always diagnosed histologically as it resembles other benign skin lesion clinically. One must first rule out cutaneous metastasis of various internal malignancies that may appear similar on histology. A variety of immunohistochemical markers as well as CK7, CK20, CDX2, GCDFP-15 and p63 are utilized to differentiate these tumours from metastases of breast or gastrointestinal malignancies.
P5. CASE REPORT OF PNEUMATOSIS CYSTOIDES INTESTINALIS
Chelvam RAJESVARAN¹, Nurul Hidayah MUSA², Shobana MUKUNDA DEVAN²
¹Department of Pathology, Hospital Umum Sarawak, Kuching, Sarawak.
²Department of Pathology, Hospital Selayang, Selangor.
Introduction:
Pneumatosis cystoides intestinalis is a rare benign disease, characterized by the presence of gas-filled cysts in the intestinal submucosa and subserosa. It has a wide aetiology, such as pyloric stenosis and systemic sclerosis, and is primarily diagnosed via clinical and imaging modalities. Furthermore, the management is largely conservative unless clinical presentation necessitates surgical intervention.
Clinical Case:
48-year-old gentleman with history of gastroduodenal junction stricture presented with abdominal distention. Oesophagogastroduodenoscopy (OGDS) showed distended stomach with a chronic ulcer at the posterior wall of the antrum, with inability to pass the scope beyond pylorus. Clinical impression was gastric outlet obstruction secondary to chronic pyloric ulcer, proceed with distal gastrectomy, resection of jejunum and terminal ileum with omentum. Macroscopically, the resected terminal ileum showed patchy areas of vesicular formations at the serosal surface, which were empty on sectioning. Cut section of the bowel wall also revealed similar empty vesicles. Microscopic examination of the vesicles showed dilated cystic spaces lined by epithelioid macrophages and foreign-body type multinucleated giant cells. No definite lining epithelium was otherwise identified and no evidence of malignancy. The partial gastrectomy specimen showed ectopic pancreatic tissue with hypertrophic pylorus.
Discussion:
Pneumatosis cystoides intestinalis may be rarely encountered by the pathologist as it is not often resected. It may occur anywhere within the gastrointestinal tract but is most common in the small intestine. Clinical presentation is variable, ranging from benign symptoms to life-threatening complications, such as intestinal obstruction as seen in this case. On endoscopic examination, bubble-like nodules may be seen, however in some cases, this finding may be obscured. X-ray usually shows intraluminal intestinal air bubbles. Pathologic features are characteristic, and identification of the underlying aetiology is helpful in further patient management.
P6. CATCH ME IF YOU CAN: THE CASE OF THE ELUSIVE PROSTATE CARCINOMA
Chelvam RAJESVARAN¹, Sarah CHIANG Pik Yan², Shobana Mukunda DEVAN², Zahrah TAWIL², Rosna YUNUS³
¹Department of Pathology, Hospital Umum Sarawak, Kuching, Sarawak.
²Department of Pathology, Hospital Selayang, Selangor.
³Department of Pathology, Hospital Kuala Lumpur, Kuala Lumpur.
Introduction:
Sarcomatoid adenocarcinoma is a highly aggressive, rare form of prostate cancer with poor prognosis. It is composed of admixture of epithelial and mesenchymal components, either one of which may predominate. We report a case with prominent sarcomatous component, and discuss relevant histological and immunohistochemical features to achieve satisfactory diagnosis.
Clinical Case:
53 years old gentleman with underlying diabetes mellitus and hypertension, presented with haematuria and obstructive uropathy, initially treated as prostatic abscess. Pre-operative transurethral resection of prostate (TURP) specimen was reported as high grade prostatic sarcoma. Computed tomography (CT) scan of the thorax, abdomen and pelvis showed extensive, locally infiltrative prostatic tumour. He subsequently underwent pelvic exenteration surgery. Macroscopically, examination of the pelvic exenteration specimen showed enlarged, distorted and extensively necrotic prostate, and globular enlarged bladder with tumour infiltration at bladder base. Microscopically, sarcomatous stromal malignancy was seen, however the lymph node showed adenocarcinomatous metastasis. Extensive tumour sampling was carried out, and showed carcinomatous (14.5%, acinar adenocarcinoma, Gleason Patterns 3 and 4) and mesenchymal (up to 30%, poorly differentiated sarcoma with focal osteosarcomatous) components. Neoplastic stromal cells which showed reactivity for vimentin and SMA only, were focally seen in close admixture with malignant glands which were positive for AMACR and PSA.
Discussion:
In literature, histologic type of carcinosarcoma has not been found to correlate with survival and overall this malignancy has poor prognosis. We report a rare case of sarcomatoid adenocarcinoma of the prostate with predominant sarcomatous component. High index of suspicion, careful histopathological examination and use of immunohistochemistry aid in cases of doubtful diagnosis.
P7. EOSINOPHILIC LIVER ABSCESSES MIMICKING HEPATIC MALIGNANCY
Venupriya Ramasamy¹, Diana Bee Lan Ong¹.
¹Department of Anatomic Pathology, University Malaya Medical Centre.
Introduction:
Eosinophilic liver abscesses are commonly discovered incidentally on radiologic examinations resembling metastases in correlation with eosinophilia. Here, we report a case of isolated eosinophilic liver abscesses mimicking malignancy.
Clinical Case:
42-year-old male with incidental finding of liver lesion at segment 6/7 liver. Hepatitis screening was negative however full blood count showed eosinophilia. MRI of liver mass was suggestive of malignancy thus right posterior hepatectomy was done. Histopathological examination showed massive expansion of the portal tracts obscured by heavy sheets of eosinophils aggregates spilling into liver parenchyma, distorting the normal architecture. Within the eosinophilic aggregates, varying sized granuloma with central area of necrosis are seen. No evidence of malignancy was identified.
Discussion:
Hypereosinophilic syndrome (HES) is characterized by marked peripheral blood hypereosinophilia with evidence of eosinophil mediated end organ damage. This is a diagnosis of exclusion after secondary causes of eosinophilia such as parasitic infections, drug hypersensitivity, allergic diseases, malignancies and collagen vascular diseases have been omitted with confidence. HES causes tissue damage by eosinophilic infiltration and activation thus releasing preformed mediators. In HES, hepatic involvement is common (40-90%) and the radiographic findings of the liver may demonstrate multiple, small, poorly defined, round to oval nodular lesions mimicking metastases especially in patients with prior history of malignancy. This unfortunately may lead to unnecessary surgery. In the end, management of HES is mainly determined by clinical presentation and degree of organ damage, wherein corticosteroid is the first line of management with second-line steroid sparing agents including hydroxyurea and imatinib.
P8. METASTASIS INVASIVE THYMOMA TO THE BRAIN AS POSTERIOR FOSSA MASS: A CASE REPORT
Lee Fong Wan, Adam Malik Bin Ismail
Hospital Umum Sarawak.
Introduction:
Thymic tumours are rare tumours arising from thymic tissue and account for 20% anterior mediastinal neoplasms in adults. The World Health Organization divided the thymic tumours into thymoma (subtype A, AB, B1, B2, B3) and thymic carcinoma (type C) based on their histological features.
Clinical Case:
We describe a 59-year-old man presented with headache for 2 years with cerebellar sign on examination. Magnetic resonance (MR) imaging showed two extra-axial lesions at posterior fossa lesions with CT thorax showed an anterior mediastinal mass. Histological examination showed proliferation of polygonal shape neoplastic cells arranged in clusters, lobules and nest. These cells showed strong and diffuse positivity for CKAE1/3, p63 and CK5/6, and focally CD5. Overall features are compatible with thymoma B3. There is sprinkling of lymphocytes with occasional perivascular space and rare mitoses seen.
Discussion:
About 30% of the thymoma are invasive; however, metastasis beyond the thorax are rare, generally to pleural, bones, liver or brain in approximately 7% of cases. Metastasis to distant (extrathoracic) site designated Stage IV in Masaoka system, which indicates much worse prognosis.
P9. PULMONARY SCLEROSING PNEUMOCYTOMA OF THE LUNG WITH SPINDLE STROMAL CELLS; A POTENTIAL PITFALL IN BIOPSY SPECIMEN
Lee Fong Wan, Adam Malik Bin Ismail
Hospital Umum Sarawak.
Introduction:
Pulmonary sclerosing pneumocytoma (PSP) is a rare benign neoplasm of pneumocytic origin, seen in middle aged adult with striking female predominance (80%).The patient are usually asymptomatic, with well circumscribed nodule or mass on imaging.
Clinical Case:
An asymptomatic 55 years old female in which incidental left hilar mass in chest x-ray, and left lingular lung mass suggestive of malignancy detected in CT thorax. The transbronchial biopsy shows dual population of cells with significant amount of solid area consists of spindle cells rather than round stromal cells. The more classical papillary and sclerotic patterns are also seen, focally. The spindle cells are positive for TTF-1 and EMA, and thus preclude the diagnosis of other tumour of mesenchymal origin. Wedge resection of left lingular mass was done and the finding was consistent with the biopsy.
Discussion:
Pulmomonary sclerosing pneumocytoma was first described as pulmonary sclerosing hemangioma years ago. However, the origin of the cells from primitive respiratory epithelium was revealed by immunohistochemical studies. Histologically, it is consisting of a dual population of cuboidal surface cells and stromal round cells. Both of the cells type have slightly different histogenetic profiles but all considered to be neoplastic. Diagnosis made based on small biopsy can be challenging, as PSP can be a mimicker for adenocarcinoma. Dense spindle stromaL cells changes may further cause a diagnostic confusion of other mesenchymal tumour, including synovial sarcoma, solitary fibrous tumour and inflammatory myofibroblastic tumour.
P10. SECRETORY BREAST CARCINOMA: EXPECT THE UNEXPECTED
FongJuen KIEW¹, PeiYeing TEOH¹, Shobana MUKUNDA DEVAN¹, Noranizah WAGINO²
¹Department of Pathology, Hospital Selayang, Selangor.
²Department of Pathology, Hospital Pakar Sultanah Fatimah, Muar, Johor.
Introduction:
Secretory breast carcinoma is a rare histological subtype of invasive breast cancer, accounting for <0.15% of all breast cancer. It is identified by its distinct histomorphology with a favorable prognosis. Although it was originally described as a juvenile breast carcinoma, occurring in young children, most cases have been reported in adults.
Clinical Case:
A 22-year-old Malay female presented with 4 months’ right breast lump, associated with bloody nipple discharge. A 3 cm x 3 cm breast lump palpated during physical examination. Ultrasound and mammogram detected a heterogenous mass measuring 3.3 x 1.1 x 3.1 cm. There is no evidence of regional lymphadenopathy or metastatic disease. Biopsy revealed an invasive breast carcinoma. Wide local excision and axillary clearance were performed. Grossly, of the lumpectomy specimen showed a solitary yellow-tan tumour with pushing borders. Microscopically, the tumour is well-circumscribed, multinodular with solid growth pattern and prominent cystic spaces containing dense eosinophilic secretory material and <10% tubular architecture. They exhibit moderate nuclear pleomorphism. Mitotic activity is low. No lymphovascular invasion is detected. The malignant cells are positive for CK7, e-cadherin, EMA and they are triple negative. The secretory material and intracytoplasmic secretion are positive for PAS and PAS diastase resistant.
Discussion:
Secretory breast carcinoma is an indolent and rare breast cancer. The presence of intracellular and extracellular secretory material that stains positive for PAS is a consistent finding. Most tumors stain positive for EMA and S100 and negative for ER, PR and HER2 (ie, triple negative). Some secretory carcinomas demonstrate a basal-like immunoprofile. Recently, the tumor was found to be associated with a distinct ETV6-NTRK3 gene translocation. The methods of surgical treatment and the role of adjuvant therapy remain controversial.