Purpose Carcinoma Cuniculatum (CC) is an exceptionally rare variant of squamous cell carcinoma with limited description in the literature. Oral Carcinoma Cuniculatum (OCC) continues to be a diagnostic dilemma as it generally presents as an indolent infection, often undergoing multiple biopsies and debridements prior to definitive diagnosis. This study aims to review the diagnostic challenges, clinical features, histopathology, and management of OCC. We specifically present a unique case of OCC in a patient with human immunodeficiency virus (HIV). Methods A review of the current literature on OCC was conducted, focusing on diagnostic delays, clinical presentation, histopathologic characteristics, and treatment approaches. Additionally, a case report of a 47-year-old male with OCC is presented, including clinical course, diagnostic workup, and management. Results The patient underwent multiple biopsies and surgical debridements over a 3-year period prior to definitive diagnosis. He was ultimately treated with subtotal maxillectomy and radial forearm free flap reconstruction. Final pathology demonstrated pT4a OCC. His clinical course was further complicated by previously undiagnosed HIV infection. Multidisciplinary tumor board recommendations included bilateral elective neck dissections and adjuvant radiation therapy. Conclusion OCC remains a diagnostic challenge due to its indolent behavior and nonspecific presentation, often resulting in delayed diagnosis and advanced disease at treatment. This case highlights the importance of maintaining clinical suspicion for malignancy in persistent oral lesions and may represent the first reported case of OCC in a patient with HIV, thus raising new questions regarding the potential role of immunosuppression while propagating prior inquiries.

Nodular fasciitis (NF) is a self-limiting mesenchymal neoplasm that typically occurs in the subcutaneous tissue of the extremities, trunk, and head and neck region; involvement of the parotid gland is very rare. The cytological features of NF can closely mimic those seen in salivary gland neoplasms, particularly pleomorphic adenoma (PA), potentially leading to misdiagnosis. We present the case of a 19-year-old female with a parotid gland mass, initially diagnosed as a salivary gland neoplasm on fine needle aspiration (FNA), but ultimately confirmed to be NF following thorough examination of the surgically resected specimen. Distinguishing NF from PA and other primary salivary gland neoplasms is crucial for appropriate management. A more definitive diagnosis of NF can be established on cytological material using ancillary studies, particularly in situ hybridization (ISH) analysis for USP6 rearrangement, thereby guiding more appropriate clinical management. This report aims to highlight this important diagnostic pitfall and alert cytopathologists by providing an illustrative example.

OBJECTIVES:To determine if the assessment of CD8+ tumor-infiltrating lymphocytes (TILs) adds prognostic information to the PD-L1 combined positive score (CPS) in recurrent/metastatic (R/M) head and neck squamous cell carcinoma (HNSCC). METHODS:A retrospective case series was performed of 77 patients with R/M HNSCC between 2003 and 2019. From pre-treatment biopsies, CD8+ TILs and PD-L1 CPS were quantified on a tissue microarray. Associations of biomarkers with overall survival and immune checkpoint inhibition (ICI) response were assessed. RESULTS:Neither CD8+ TIL counts nor PD-L1 CPS alone were associated with overall survival; however, combined high TILs and CPS ≥ 1 were associated with improved survival compared to low TILS and CPS < 1 (18.5 vs. 10.0 months, p = 0.058). For patients treated with ICI (n = 28), PD-L1 CPS predicted ICI response more strongly than CD8+ TILs. CONCLUSIONS:In R/M HNSCC, the combination of PD-L1 CPS and CD8+ TILs is a stronger prognostic biomarker for overall survival compared with either biomarker alone.

PRRX1-rearranged mesenchymal/fibroblastic tumor is a recently proposed, molecularly defined soft tissue tumor, which has not yet been included in the WHO's most recent edition of soft tissue tumors. This entity has previously been reported in a wide age range (20-76 years). However, we report the first pediatric case in an 11-year-old patient presenting with 5.5 cm mass in the head and neck region. Our case is also the second reported case of a PRRX1 (exon 1)::NCOA1 (exon 15) fusion transcript to date.

Fine needle aspiration (FNA) is widely accepted as an efficient first-line diagnostic tool for evaluating salivary gland lesions. It can accurately diagnose a majority of common benign tumors, including pleomorphic adenoma (PA). However, PA can exhibit a wide range of morphological variations, which may lead to misinterpretation. Here, we present a case in which degenerative myoepithelial cells with nuclear atypia in PA were misinterpreted as malignant. Furthermore, PLAG1 false negativity in cell block material compounded the diagnostic challenge. This report aims to highlight this diagnostic pitfall and alert cytopathologists by providing an illustrative example.

Mucoepidermoid Carcinoma (MEC) is a common salivary malignant neoplasm. Approximately 60 % of MECs harbor translocations between CRTC1 or CRTC3 and MAML2, which are thought to drive disease pathogenesis. However, the precise structural mechanism driving this rearrangement remains uncharacterized. Here, we performed multi-omic and long read genomic sequencing, discovering a chain of alterations that created the CRTC1::MAML2 fusion, but also an unexpected MAML2 to MYBL1 rearrangement, suggesting that MYBL1 may play a larger role in salivary gland cancers than previously recognized. Furthermore, we discovered and validated recurrent TERT rearrangements and amplifications in MEC models. 5/5 MEC cell lines and 36/39 (92 %) primary MEC tumors harbored a TERT rearrangement or copy number amplification. Custom sequencing of the TERT locus confirmed translocation breakpoints in 13/33 (39 %) MECs, while exome sequencing confirmed frequent TERT amplifications. Critically, TERT knockdown in NCI-H292, a cell line with TERT promoter rearrangement, reduced clonogenic cell survival, supporting a critical role of this gene in MEC tumorigenesis. Overall, our data suggest that complex chromothripsis rearrangement mechanisms drive the formation of structural variation in CRTC1::MAML2 fusion positive and negative tumors and reveal highly recurrent structural variation driving TERT rearrangement in MEC.

OBJECTIVE:We evaluated vessel counts in the pharyngeal mucosal margins of patients who underwent salvage laryngectomy to establish whether mucosal vascularity might predict fistula risk. STUDY DESIGN:Retrospective cohort. SETTING:Tertiary Medical Center. METHODS:Patients who underwent salvage total laryngectomy at our institution between 1999 and 2015 were identified. Pharyngeal mucosal margins from laryngectomy specimens were evaluated histologically for each patient, and vessel counts were performed on 5 ×10 images. The primary outcome measure was fistula within 30 days of surgery and mean vessel counts were assessed as the principle explanatory variable. RESULTS:Seventy patients were included and 40% developed a postoperative fistula. There was a large difference in the mean vessel count in patients who did develop fistula (48.6 vessels/×10 field) compared to those who did not (34.7 vessels/×10 field). A receiver operative characteristic curve found that a cutoff value of 33.9 vessels/×10 field provided a sensitivity of 75% and specificity of 62% to predict the likelihood of fistula occurrence (area under the curve = 0.71, 95% confidence interval [CI]: 0.59-0.83). In a binary logistic regression, patients with vessel counts greater than 33.9 had a 5-fold increased risk of developing fistula (95% CI: 1.8-16.45). Histologically, vessels in the pharyngeal mucosa of patients who developed fistulas were more disorganized. CONCLUSION:After salvage laryngectomy, patients with higher mean mucosal margin vessel counts are at increased risk of fistula. The mechanism is unknown, but the disorganization of the vasculature may contribute to poor wound healing. Vessel counting may allow for fistula risk stratification and guide postoperative care.

PURPOSE:To describe the clinical features of a conjunctival apocrine hidrocystoma that developed 6 decades after a strabismus surgery and review existing literature on apocrine hidrocystomas of the conjunctiva and caruncle.METHODS:Case report and review of literature on conjunctival apocrine hidrocystomas.RESULTS:A 71-year-old man with a history of strabismus surgery as a child presented with a cystic lesion on the nasal conjunctiva and caruncle for 1 year. Excision of the lesion showed a unilocular cavity lined by a double layer of cells with the hallmark finding of apical decapitations, confirming a diagnosis of apocrine hidrocystoma. Seven additional cases of conjunctival and caruncular apocrine hidrocystomas were reviewed. All cases presented after 50 year of age. Most cases presented nasally or within the caruncle and had a pigmented appearance. No other reported cases had a history of trauma or surgery. All cases were treated with surgical excision without recurrence.CONCLUSIONS:History of strabismus surgery or conjunctival trauma may lead to ectopic deposition of apocrine glands that may contribute to the formation of an apocrine hidrocystoma.

Supplementary Table 3: Swallowing Function

Oral cavity squamous carcinoma is characterized by alterations in cell mediated tumor immunity including a lack of immune reactive tumor infiltrating lymphocytes (TILs). To determine if a novel neoadjuvant injection of a multi-cytokine biologic (IRX-2) can restore immune reactivity and enhance patient survival, a randomized Phase 2 clinical trial was conducted in patients with Stage II-IV OSCC undergoing surgical resection (NCT 02609386).The intention-to-treat (ITT) enrollment included 105 previously untreated patients, however 9 were excluded from the secondary endpoint analysis group for wrong histology, no treatment or patient refusal. A total of 96 patients comprised the final analytic group and were randomized (2:1) to receive the IRX-2 regimen (Regimen 1) compared to the identical regimen without IRX-2 cytokines (Regimen 2). Toxicity, tumor and immune responses, event-free (EFS) and overall (OS) survival were determined. Kaplan-Meier estimates for OS and EFS and inferential comparisons and asymptotoic log-rank testing between the two treatments were determined.In prior preliminary analysis, significant increases in TILs and DMBT1 gene expression were noted for the IRX arm. No significant correlations of immunologic or tumor responses with survival outcomes were found. For the ITT population (n=105) there were no significant differences in OS by treatment arm. OS [95% CI] at 48 mo. was 70.4 [57.6, 80.0] vs 66.3 [47.5, 79.8] mos. (Regimen 1 vs Regimen 2, respectively). Conclusions Significant differences in survival were not seen, however, the trial demonstrated the feasibility of the neoadjuvant immunotherapy and differing immune modulation in each treatment arm. No correlations of immune biomarkers or tumor size changes with survival outcomes were identified.

Mycobacterial spindle cell pseudotumors (MSPs) are a rare and diagnostically challenging manifestation of non-tuberculous mycobacterial (NTM) infections. Proper recognition of these pseudotumors is important because they are treatable and benign. In this study, we evaluated the morphologic patterns of MSPs to improve their pathologic identification. Clinical and morphologic features of 14 MSPs were analyzed. Histologic factors evaluated included the architectural growth pattern of spindled or epithelioid macrophages, granulomas and their location within the lesion, neutrophilic microabscesses, multinucleated giant cells, necrosis, and effacement of background tissue. The composition of inflammatory infiltrates, organism density by acid-fast staining, and stromal changes were also assessed. In addition, 8 of 14 cases underwent molecular microbiology identification by a clinical amplicon-sequencing assay for non-tuberculous mycobacteria. MSP sites included 2 bowel, 10 lymph nodes, 1 liver, and 1 extremity. Cases with available clinical history (n=10) all occurred in immunocompromised patients. All demonstrated effacement of normal structures with spindled cells arranged in a storiform or fascicular architectural pattern. In addition, all cases showed lymphocytic inflammation, with prominent concurrent neutrophilic inflammation in 50% (7/14) of cases. Other morphologic findings included foamy histiocytes (64%, 9/14), peripherally situated granulomas (21%, 3/14), and neutrophilic microabscesses (21%, 3/14). All tested cases were positive for NTM by PCR methods. Mycobacterium avium was the most commonly isolated pathogen (6/8). Mycobacterial spindle cell pseudotumors show predominantly spindled morphology that may be mistaken as a neoplasm. Surgical pathologists who evaluate lymph nodes, soft tissue, and gastrointestinal tissues should be aware of this spindled tumefactive phenomenon in the setting of immunocompromised patients. Recognition of key morphologic features of neutrophilic inflammation, peripheral granulomas, or foamy histiocytes within a spindled lesion can help guide the pathologist to a correct diagnosis of an inflammatory process secondary to infection rather than a spindle cell neoplasm. Accurate diagnosis to facilitate appropriate antimicrobial and/or surgical therapy requires a comprehensive evaluation combining clinical, histopathologic, and microbiological findings.

Supplementary Table 2: Change in Stage with Neck Dissection

Abstract Purpose: Locoregionally advanced HPV+ oropharyngeal squamous cell carcinoma (OPSCC) has excellent cure rates, although current treatment regimens are accompanied by acute and long-term toxicities. We designed a phase II deescalation trial for patients with HPV+ OPSCC to evaluate the feasibility of an upfront neck dissection to individualize definitive treatment selection to improve the quality of life without compromising survival. Patients and Methods: Patients with T1–3, N0–2 HPV+ OPSCC underwent an upfront neck dissection with primary tumor biopsy. Arm A included patients with a single lymph node less than six centimeters, with no extracapsular spread (ECS) and no primary site adverse features underwent transoral surgery. Arm B included patients who had two or more positive lymph nodes with no ECS, or those with primary site adverse features were treated with radiation alone. Arm C included patients who had ECS in any lymph node and were treated with chemoradiation. The primary endpoint was quality of life at 1 year compared with a matched historical control. Results: Thirty-four patients were enrolled and underwent selective neck dissection. On the basis of pathologic characteristics, 14 patients were assigned to arm A, 10 patients to arm B, and 9 to arm C. A significant improvement was observed in Head and Neck Quality of Life (HNQOL) compared with historical controls (−2.6 vs. −11.9, P = 0.034). With a median follow-up of 37 months, the 3-year overall survival was 100% and estimated 3-year estimated progression-free survival was 96% [95% confidence interval (CI), 76%–99%]. Conclusions: A neck dissection–driven treatment paradigm warrants further research as a deintensification strategy.

Mycobacterial spindle cell pseudotumors (MSPs) are a rare and diagnostically challenging manifestation of non-tuberculous mycobacterial (NTM) infections. Proper recognition of these pseudotumors is important because they are treatable and benign. In this study, we evaluated the morphologic patterns of MSPs to improve their pathologic identification. Clinical and morphologic features of 14 MSPs were analyzed. Histologic factors evaluated included the architectural growth pattern of spindled or epithelioid macrophages, granulomas and their location within the lesion, neutrophilic microabscesses, multinucleated giant cells, necrosis, and effacement of background tissue. The composition of inflammatory infiltrates, organism density by acid-fast staining, and stromal changes were also assessed. In addition, 8 of 14 cases underwent molecular microbiology identification by a clinical amplicon-sequencing assay for non-tuberculous mycobacteria. MSP sites included 2 bowel, 10 lymph nodes, 1 liver, and 1 extremity. Cases with available clinical history (n=10) all occurred in immunocompromised patients. All demonstrated effacement of normal structures with spindled cells arranged in a storiform or fascicular architectural pattern. In addition, all cases showed lymphocytic inflammation, with prominent concurrent neutrophilic inflammation in 50% (7/14) of cases. Other morphologic findings included foamy histiocytes (64%, 9/14), peripherally situated granulomas (21%, 3/14), and neutrophilic microabscesses (21%, 3/14). All tested cases were positive for NTM by PCR methods. Mycobacterium avium was the most commonly isolated pathogen (6/8). Mycobacterial spindle cell pseudotumors show predominantly spindled morphology that may be mistaken as a neoplasm. Surgical pathologists who evaluate lymph nodes, soft tissue, and gastrointestinal tissues should be aware of this spindled tumefactive phenomenon in the setting of immunocompromised patients. Recognition of key morphologic features of neutrophilic inflammation, peripheral granulomas, or foamy histiocytes within a spindled lesion can help guide the pathologist to a correct diagnosis of an inflammatory process secondary to infection rather than a spindle cell neoplasm. Accurate diagnosis to facilitate appropriate antimicrobial and/or surgical therapy requires a comprehensive evaluation combining clinical, histopathologic, and microbiological findings.

Supplemental Table 1: Representativeness of Study Participants

Ganglioneuromas are benign tumors arising from the neural crest. Histologically, they are composed of mature Schwann cells and ganglion cells admixed with fibrous tissue. While they frequently are seen in the abdomen and mediastinum, rare reports have highlighted their occurrences in the genitourinary system. The only prior reported prostatic ganglioneuroma arose in a patient with a history of neurofibromatosis type 1. In this report, we highlight the first reported prostatic ganglioneuroma without a known genetic linkage.

Neoplasm-associated genes on chr3q and chr16q (identified by gene2Mesh). - The 'logFC', 'p-value' and 'q-value' columns are from testing the expression difference between HPV-KRT and HPV-IMU tumors (UM and TCGA combined).

Differential mRNA expression of genes with copy number alterations. The relative mRNA expression of amplified genes was assessed across the all publically available next generation sequencing data where matched genome or exome-sequencing and transcriptome sequencing were available using the Oncomine database. Three plots were generated for each gene with copy number alterations, the respective gene is indicated on top of the plot. RNA expression was not evaluable for TCGA-CN-A49A, which harbored a SMOC1 amplification. DNA copy number calculated from exome or whole genome sequencing data is shown along the x-axis and absolute fragments per kilobase million are shown along the y-axis (Values are presented as Log base 2). Samples within the plots have either do not have genomic alterations or have mutations, gene fusions or copy number alterations as indicated in the inset legend. Blue dashed line indicates the limit for calling genomic deletions and the pink line for genomic amplifications. The black line indicates best fit for correlation between DNA copy number and gene expression.

Summary of Integration Transcription Analysis in HPV16-Positive Tumors. (F), (R) = Forward or Reverse viral orientation in relation to the cellular gene. Bold text= Viral/cellular fusion transcript, Italicized text=Transcript spans integration site, Grey shade= No transcript produced, a = Nonsense sequence, no alignment, b= Sequence was correct and spliced in frame, c= Sequence mapped to unexpected or rearranged sequences.