Gastric outlet obstruction (GOO) is a common clinical presentation characterized by epigastric abdominal pain, nausea, vomiting, early satiety, and weight loss. Common causes of GOO in adults include GI malignancies, PUD, and polyps. PUD has become a less common etiology since the advent of acid suppression and H. pylori eradication; today, it accounts for less than five per cent of cases. Malignancy is now the most common cause of GOO, accounting for more than 50 per cent of cases.1 Among this cohort, distal gastric cancer is the most common etiology, but less frequent malignant causes, including pancreatic adenocarcinoma, locally invasive gallbladder carcinoma or cholangiocarcinoma, and metastatic or primary duodenal malignancy, should also be considered. The etiology of GOO can be determined based on clinical findings, physical examination, endoscopy, and radiologic evaluation. Endoscopy can be both diagnostic and therapeutic and is useful in identifying a malignant-appearing mass that may cause obstruction; however, endoscopic biopsy has a poor sensitivity and, if negative, does not rule out malignancy as the cause of GOO. Further evaluation to rule out malignancy is therefore warranted in patients with negative endoscopic biopsies, but who are aged more than 50 years, have a positive family history of gastric cancer, and have no history of PUD.2 Furthermore, if endoscopic biopsies are positive for malignancy, a primary GI tumor is often presumed to be the underlying cause of obstruction despite the possibility, albeit rare, of metastatic disease to the duodenum arising primarily from outside the abdomen. In this case report, we describe a patient who presented with GOO caused by duodenal metastasis from breast cancer. We also present a literature review on this topic. A 79-year-old woman with a medical history significant for hypertension, dyslipidemia, peripheral vascular disease, and dementia presented to the ED with nausea, vomiting, and a 40-pound weight loss. She complained of abdominal pain for the past six months, along with early satiety and reflux. Her physical examination was significant for a distended abdomen. Her laboratory work showed elevations in aspartate aminotransferase (287), alanine aminotransferase (231), alkaline phosphatase (136), total bilirubin (2.1), and calcium (11.2), and decreased hemoglobin (11.8), platelets (136k), albumin (3.1), and prealbumin (13.4). She underwent a CT scan of her abdomen and pelvis, which showed GOO with a large soft tissue mass near the duodenum and a dilated biliary tract (Fig. 1). She was treated with nasogastric tube decompression, after which she underwent an endoscopic retrograde cholangiopancreatography, which was subsequently aborted because of duodenal stricture and an infiltrating mass seen in the major and minor papillae of the duodenum. Multiple biopsies were obtained during the procedure, which demonstrated poorly differentiated signet ring adenocarcinoma. The patient underwent a chest CT as a part of staging workup of suspected duodenal adenocarcinoma; the chest CT showed a spiculated mass in her left breast measuring 2.7 · 1.6 cm (Fig. 2). On physical examination, the patient had a hard, fixed left breast mass with no palpable lymph nodes. Further questioning revealed that the patient had never had a screening mammogram and she had a family history significant for a sister with breast cancer in her mid-50s. She subsequently underwent ultrasoundguided core needle biopsy that showed poorly differentiated invasive lobular carcinoma with occasional signet cells. IHC stains of the breast mass and the duodenal mass were positive for CAM 5.2 and CK 7; reactive for GCDFP-15, GATA-3, estrogen receptor, and progesterone receptor; and negative for E-cadherin, CK Address correspondence and reprint requests to Erika Elliott, B.S., Department of Surgery, Tulane School of Medicine, 1430 Tulane Avenue, SL-22, New Orleans, LA 70112. E-mail: eelliot4@ tulane.edu.

Background Challenges remain for establishing a specific diagnosis in cases of interstitial lung disease (ILD). Bronchoscopic lung cryobiopsy (BLC) has impacted the diagnostic impression and confidence of multidisciplinary discussions (MDDs) in the evaluation of ILD. Reports indicate that a genomic classifier (GC) can distinguish usual interstitial pneumonia (UIP) from non-UIP. Research Question What is the impact of sequentially presented data from BLC and GC on the diagnostic confidence of MDDs in diagnosing ILD? Study Design and Methods Two MDD teams met to discuss 24 patients with ILD without a definitive UIP pattern. MDD1 sequentially reviewed clinical-radiologic findings, BLC, and GC. MDD2 sequentially reviewed GC before BLC. At each step in the process the MDD diagnosis and confidence level were recorded. Results MDD1 had a significant increase in diagnostic confidence, from 43% to 93% (P = .023), in patients with probable UIP after the addition of GC to BLC. MDD2 had an increase in diagnostic confidence, from 27% to 73% (P = .074), after the addition of BLC to GC. The concordance coefficients and percentage agreement of categorical idiopathic pulmonary fibrosis (IPF) and non-IPF diagnoses were as follows: GC vs MDD1: 0.92, 96%; GC vs MDD2: 0.83, 92%; BLC1 vs MDD1: 0.67, 83%; BLC2 vs MDD2: 0.66, 83%. Interpretation GC increased diagnostic confidence when added to BLC for patients with a probable UIP pattern, and in appropriate clinical settings can be used without BLC. In contrast, BLC had the greatest impact regarding a specific diagnosis when the likelihood of UIP was considered low following clinical-radiographic review.

The Splendore-Hoeppli phenomenon is histopathologically characterized by the presence of radiating club-like eosinophilic material composed of antigen-antibody complex around infectious and noninfectious agents. We report an extremely rare case of a Splendore-Hoeppli-like phenomenon in bone in a 44-year-old man with a 5-year history of an abscess of the right lateral thigh. The abscess was treated with irrigation and debridement with corresponding tissue cultures that were positive for methicillin-resistant Staphylococcus aureus at outside facility. The patient was admitted to our facility for evaluation of his osteomyelitis. Sections of the bone debridement showed acute suppurative and chronic fibrosing osteomyelitis with osteonecrosis, inflamed granulation tissue, and Splendore-Hoeppli-like phenomenon cuffing the surface of necrotic bone trabeculae. The Splendore-Hoeppli-like phenomenon in the bone showed characteristic spike and club-like basophilic projections on the surface of necrotic bone trabeculae on hematoxylin and eosin staining. The basophilic character of these clubs differs from the classic acidophilic clubs seen in the typical examples of Splendore-Hoeppli phenomenon. Concurrent stains showed purple club-like deposits with the trichrome, PAS, and Gram stains, black club-like deposits with the GMS stain, and pink club-like deposits with the Fite stain in the areas of Splendore-Hoeppli-like phenomenon. The Splendore-Hoeppli phenomenon has been reported in fungal, bacterial, and parasite infections, and in allergic states including hypereosinophilic syndrome and allergic granulomas. The Splendore-Hoeppli phenomenon might accompany actinomycotic infections and chronic bacterial infections (botryomycosis). The Splendore-Hoeppli phenomenon can be seen at various locations such as skin, conjunctiva, and internal organs. However, the Splendore-Hoeppli phenomenon in bone is extremely rare. In the present case report, on the tissue Gram stain, focal punctate Gram-positive structures suggestive of cocci are identified at the interface of the reactive bone and the overlying Splendore-Hoeppli-like reaction. Given the basophilic character of the club-like projections, this process is classified as Splendore-Hoeppli-like phenomenon.

Primary squamous cell carcinoma (SCC) of the thyroid gland is a very rare entity representing <1% of all primary carcinomas of the thyroid gland. It affects usually older patients between the fifth and sixth decade, and is usually an aggressive entity with very poor prognosis. In this report, we describe a 66-year-old female patient who presented for evaluation of a 1.5 cm right thyroid mass with worsening hoarseness and dysphagia over the course of 3 months. Fine needle aspiration of the thyroid mass was positive for carcinoma; further classification was precluded by non-definitive cytologic features and limited material for immunohistochemical stains. Total thyroidectomy and central neck dissection were subsequently performed. The right thyroid lobe showed invasive poorly differentiated squamous carcinoma, positive for PAX8 but negative for thyroglobulin and TTF1, with acantholytic component and minimal focal mucin production. The entrapped thyroid tissue within the carcinoma was positive for all of the above markers, serving as “built-in” positive controls. PAX8 is expressed in thyroid carcinomas but not in head and neck squamous carcinomas. These findings are consistent with SCC of primary thyroid origin, with minimal secretory/mucin production. Chest CT scan showed numerous bilateral pulmonary nodular opacities with core biopsy revealing invasive poorly differentiated SCC consistent with metastatic disease. Neck CT scan showed 6 cm residual tumor in the glottic and subglottic areas with soft tissue invasion of C5. Patient was scheduled for chemotherapy and radiotherapy. Primary thyroid SCC has poor response to chemotherapy and total excision is usually recommended; hence, it should be differentiated from secondary involvement of adjacent SCC or metastases from other sites. To the best of our knowledge, this is the first case report of primary SCC of the thyroid with lung metastasis.

Neurofibromatosis is a multisystemic disease in which the multiple possible clinical manifestations may have important diagnostic and prognostic implications; if arterial hypertension coexists, many pathogenic mechanisms justify that the possible secondary etiology must be considered. In this report we review the pathogenic and clinical mechanisms and we point to the diagnostic strategy to reveal anomalies and diseases that, although present, may be occult.

Ectopic intrathyroidal thymic tissue, with coinciding intrathymic parathyroid tissue, is a very rare occurrence that is most often found incidentally in adults during surgery. We report a 23-year-old female who presented with Graves disease refractory to medical treatment. Radioactive iodine uptake demonstrated increased, diffuse uptake in the region of the thyroid. The patient underwent a total thyroidectomy and right inferior parathyroidectomy which was found enlarged intraoperatively. Histopathologically, surgical specimen demonstrated characteristics of intrathyroidal thymic tissue and intrathymic parathyroid tissue. Intrathyroidal thymic tissue can be identified preoperatively on ultrasonography, but the significance of this finding is unknown.

Gastric adenocarcinoma of the fundic gland type (GA-FG) is a rare entity that has only recently been described and defined. There is ongoing controversy regarding the malignant potential of this lesion. We report the case of a GA-FG in a 49-year-old Caucasian man who was referred to endoscopy for management of an incidentally found gastric polyp. Endoscopy showed a single polypoid lesion in the gastric fundus which was successfully removed with endoscopic resection. Grossly, the polyp measured 1.1 cm in greatest dimension. Microscopic examination showed irregularly branched neoplastic glands covered with a nonneoplastic foveolar epithelium. The continuity between the neoplastic glands and the fundic glands is clearly identified, indicating the tumor arose from the fundic glands. The tumor cells exhibited occasional oxyntic cytoplasm with enlarged atypical nuclei. The tumor invaded the submucosa with complete disruption of the muscularis mucosae and mild lymphocytic and fibroblastic stromal reaction. No necrosis, mitosis, or lymph-vascular invasion was identified. Although some authors have proposed reclassification of GA-FGs as oxyntic gland polyps/adenomas, in light of several reported cases with submucosal invasion as well as lymphatic invasion, we maintain that this neoplasm is best categorized as an extremely well-differentiated adenocarcinoma to reflect its invasive potential.

Phenytoin was introduced in 1938 for the control of seizure disorders and remains widely used today. Since that time, many cases of phenytoin-induced allergic reactions and clinical pulmonary disease have been reported. However, pulmonary vascular pathology from phenytoin use has been only very rarely described. We report a case of phenytoin-associated vasculitis in a 39-year-old African American man presenting with progressive dyspnea and abnormal chest imaging. The importance of reviewing the medication history along with familiarity with the array of drug-associated lung diseases is crucial to recognize and treat pneumotoxicity.

Few cases of primary mucosal melanoma of the larynx have been documented in the literature, so only a limited amount of data exists regarding its diagnosis and treatment. The prognosis is poor, as patients often present at a late stage with regional or distant metastases. We describe the case of a 66-year-old man who presented with hoarseness and dysphagia. Laryngoscopy identified a dark discoloration of the supraglottic larynx and incomplete mobility of the right vocal fold; an excisional biopsy confirmed the diagnosis. We discuss the epidemiology, clinical features, diagnosis, interpretation of imaging findings, and management of this rare malignant melanoma.

Gastric adenocarcinoma of the fundic gland type (GA-FG) is a rare entity that has only recently been described and defined, and there is ongoing controversy regarding the malignant potential of this lesion. We report the case of a GA-FG in a 49-year-old …

Pigmentation within thyroid follicular cells is common and its significance uncertain. While “black thyroid” pigment is associated with chronic minocycline therapy, similar pigments may simply be age related. Although a relationship between black thyroid pigment and neoplasia has been suggested, no study has proven increased tumor development with pigmentation. By comparing the incidence of thyroid pigmentation in thyroids with neoplasms …

The case presented is that of a 63-year-old female with an unusually large solitary calvarial plasmacytoma as an initial manifestation of a multiple myeloma. We were able to follow the progression of the disease clinically and with diagnostic imaging.

A 40-year-old woman was referred to pulmonary clinic for evaluation of multiple lung nodules on chest imaging. Her past medical history was remarkable for end-stage kidney disease on peritoneal dialysis due to chronic hypertension 5 years ago and large uterine leiomyomata that led to total hysterectomy at age 30 years. Pathology diagnosis was compatible with multiple uterine corpus and cervical leiomyoma with no significant atypia and no necrosis. She is a mother of one healthy child and a lifetime nonsmoker. The patient denied cough, shortness of breath, hemoptysis, recent travel, or any other symptoms. On examination, she appeared comfortable, and the dialysis catheter site was clean. The rest of her physical examination was normal. The patient's medical history, social history, and review of systems were otherwise unremarkable. Blood work revealed the following values: sodium, 139 mmol/L; potassium, 4.9 mmol/L; bicarbonate, 22 mmol/L; BUN, 50 mg/dL; creatinine, 5.2 mg/dL; calcium, 8.7 mg/dL (8.4-10.4 mg/dL); albumin, 3.9 g/dL; phosphorus, 4.8 mg/dL (2.5-4.9 mg/dL); magnesium, 1.9 mg/dL; and hemoglobin, 11 g/dL (mean corpuscular volume, 95%). The patient's WBC count, serum bilirubin, and transaminases levels were normal. The patient's posteroanterior and lateral chest radiographs are shown in Figure 1. CT image of the chest (axial view) is shown in Figure 2. Fluorodeoxyglucose PET/CT scan showed no hypermetabolic activity.Figure 2CT scan of the chest (lung window) showing multiple, small, round, well-defined nodules.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A thoracoscopic lung biopsy of the left lower lobe through video-assisted thoracic surgery was performed. The pleural surface had a nodular protrusion and cut sections of the specimen revealed a cyst filled with brown liquid material. On hematoxylin-and-eosin stains and immunostains, the cystic lesion was lined by thyroid transcription factor-1-positive pneumocytes and there were smaller entrapped locules in the wall of the cyst which were also lined by thyroid transcription factor-1-positive pneumocytes with focal blunt mild micropapillary pneumocyte hyperplasia. The stromal wall of the cyst was myomatous, smooth muscle-like, and tested positive for desmin, estrogen receptor (ER), progesterone receptor (PR), bcl-2, CD10, and for muscle-specific actin (Fig 3). This myomatous stroma had a rich component of ectatic thin-walled vessels lined by CD31-positive endothelial cells. The cytohistologic features of the myomatous stromal and pneumocyte components were bland. There was no pleomorphism, necrosis, or conspicuous mitotic activity. The smooth muscle component was negative for HMB-45, Melan-A, α-inhibin, and CD99. Diagnosis: Benign metastasizing leiomyoma Uterine leiomyomas affect 30% of middle-aged women. These tumors, which originate from smooth muscle cells, usually arise in the female genital tract (especially the uterine corpus) but may also take origin in the GI tract and other diverse anatomic sites. Extrauterine leiomyomas can arise in the skin, vessels, and soft tissue and are uncommon and may present a diagnostic dilemma. Benign metastasizing leiomyoma is a rare disease with <100 cases reported in literature.1.Wongsripuemtet J Ruangchira-urai R Stern EJ Kanne JP Muangman N Benign metastasizing leiomyoma.J Thorac Imaging. 2012; 27: W41-W43Crossref PubMed Scopus (9) Google Scholar It was described by Steiner2.Steiner PE Metastasizing fibroleiomyoma of the uterus: report of a case and review of the literature.Am J Pathol. 1939; 15: 89-110.7PubMed Google Scholar in 1939 and usually presents in middle-aged women with history of uterine leiomyoma. Histologically, these lesions are identical to their uterine counterparts. Clinically, solitary or multiple nodules appear in the lungs and other sites and may suggest malignant metastasizing lesions, in this age group, from breast, ovary, and colon. Postulated origins of the pulmonary lesions include hematogenous metastasis from “benign” or exceedingly low-grade uterine smooth muscle tumors or from multiple independent foci of pulmonary smooth muscle proliferation. The former is currently favored as the origin for these pulmonary lesions. Low-grade smooth muscle tumors may demonstrate slow growth and remain clinically silent over a long interval.3.Abramson S Gilkeson RC Goldstein JD Woodard PK Eisenberg R Abramson N Benign metastasizing leiomyoma: clinical, imaging, and pathologic correlation.AJR Am J Roentgenol. 2001; 176: 1409-1413Crossref PubMed Scopus (137) Google Scholar It is not uncommon for reports on the lung lesions to be detected months to years posthysterectomy.4.Inayama Y Shoji A Odagiri S et al.Detection of pulmonary metastasis of low-grade endometrial stromal sarcoma 25 years after hysterectomy.Pathol Res Pract. 2000; 196: 129-134Crossref PubMed Scopus (39) Google Scholar In the present case, pulmonary lesions were detected 10 years following hysterectomy for uterine leiomyomata. Reported cases of metastasizing leiomyoma have also been described in three male patients. Leiomyoma can metastasize to different organs with the lung as the most common site.5.Wolff M Silva F Kaye G Pulmonary metastases (with admixed epithelial elements) from smooth muscle neoplasms. Report of nine cases, including three males.Am J Surg Pathol. 1979; 3: 325-342Crossref PubMed Scopus (140) Google Scholar The heart, brain, lymph nodes, bone, and skin are rarely affected. Patients with lung metastases are usually asymptomatic or have nonspecific respiratory symptoms such as cough, dyspnea, and chest pain. Clinical course is usually indolent, and diagnosis is usually made following an incidental radiographic imaging.6.Goto T Maeshima A Akanabe K et al.Benign metastasizing leiomyoma of the lung.Ann Thorac Cardiovasc Surg. 2012; 18: 121-124Crossref PubMed Scopus (19) Google Scholar In one case report, a patient presented with spontaneous pneumothorax.7.Pitts S Oberstein EM Glassberg MK Benign metastasizing leiomyoma and lymphangioleiomyomatosis: sex-specific diseases?.Clin Chest Med. 2004; 25: 343-360Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Diffuse multiple pulmonary nodules are the most characteristic radiologic findings in benign metastasizing leiomyoma. These well-defined nodules vary from solitary subcentimeter lesions to multiple lesions mimicking pulmonary metastases from malignant tumors. In our case, nodules were randomly distributed without feeding vessels, cavitation, or basilar distribution. The absence of feeding vessels attached to nodules makes hematogenous spread less likely. Calcification, cystic change, and pneumothorax are occasional variations in the presentation. Also, rare cases with a miliary or interstitial lung disease pattern have been described in the literature. The differential diagnosis of benign metastasizing lung nodules is broad but most commonly includes metastatic cancers,8.Koh DM Burn PR King DM Benign metastasizing leiomyoma with intracaval leiomyomatosis.Br J Radiol. 2000; 73: 435-437Crossref PubMed Scopus (56) Google Scholar infectious granulomas, rheumatoid nodules, sarcoidosis, metastatic pulmonary calcifications, and amyloidosis (Table 1). Lung biopsy is essential to obtain a definitive diagnosis. Most of the reported cases do not show pleural or lymph node involvement.3.Abramson S Gilkeson RC Goldstein JD Woodard PK Eisenberg R Abramson N Benign metastasizing leiomyoma: clinical, imaging, and pathologic correlation.AJR Am J Roentgenol. 2001; 176: 1409-1413Crossref PubMed Scopus (137) Google Scholar Spontaneous resolution of benign metastasizing leiomyoma has been described.9.Arai T Yasuda Y Takaya T Shibayama M Natural decrease of benign metastasizing leiomyoma.Chest. 2000; 117: 921-922Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 10.Horstmann JP Pietra GG Harman JA Cole NG Grinspan S Spontaneous regression of pulmonary leiomyomas during pregnancy.Cancer. 1977; 39: 314-321Crossref PubMed Scopus (157) Google Scholar The PET/CT scan was negative for hypermetabolism in the pulmonary lesions and did not support other metastatic lesions.3.Abramson S Gilkeson RC Goldstein JD Woodard PK Eisenberg R Abramson N Benign metastasizing leiomyoma: clinical, imaging, and pathologic correlation.AJR Am J Roentgenol. 2001; 176: 1409-1413Crossref PubMed Scopus (137) Google ScholarTable 1Differential Diagnosis of Multiple Pulmonary NodulesDiagnosesMetastatic tumorsInfectious granulomasRheumatoid nodulesSarcoidosisMetastatic pulmonary calcificationsAmyloidosisChronic hypersensitivity pneumonitisBronchiolitis-associated interstitial lung diseaseLymphoid interstitial pneumoniaInfections (eg, viral pneumonias, histoplasmosis)Pulmonary hyalinizing granulomaMalignancy (eg, multifocal adenocarcinoma) Open table in a new tab The histopathologic differential diagnosis of benign metastasizing leiomyomas includes lymphangioleiomyomatosis (LAM), metastatic low-grade endometrial stromal sarcoma, and frank metastatic leiomyosarcoma. The radiographic pattern of pulmonary nodules and the negative HMB-45 and Melan-A immunostains exclude LAM. The absence of a high mitotic rate excluded metastatic high-grade endometrial stromal sarcoma. The cytohistologic features resemble a lesion of smooth muscle rather than endometrial stromal origin. As previously mentioned, the cystic presentation of benign metastizing leiomyomas is rare, prompting rare cystic entities to be considered in the differential diagnosis such as LAM, Langerhans cell histiocytosis, and cystic nodular amyloidosis. The immunophenotype for benign metastasizing leiomyoma consists of spindle cells which are positive for desmin, smooth muscle actin, ER, PR, CD10, and bcl-2. The spindle cells are negative for S100 protein, CD117, CD34, CD99, HMB45, Melan-A, and α-inhibin. This immunoprofile matched our case. In the few reported pulmonary cystic examples of metastasizing leiomyoma, the immunophenotype was similar with immunoreactivity for desmin, smooth muscle actin, ER, PR, CD10, and bcl-2. The Ki-6711.Mittal K Soslow R McCluggage WG Application of immunohistochemistry to gynecologic pathology.Arch Pathol Lab Med. 2008; 132: 402-423PubMed Google Scholar nuclear proliferation index is typically low. Nucci et al12.Nucci MR Drapkin R Dal Cin P Fletcher CD Fletcher JA Distinctive cytogenetic profile in benign metastasizing leiomyoma: pathogenetic implications.Am J Surg Pathol. 2007; 31: 737-743Crossref PubMed Scopus (95) Google Scholar described a distinctive cytogenetic profile in benign metastasizing leiomyoma. They described five cases of benign metastasizing leiomyoma in which they identified consistent chromosomal aberrations (19q and 22q, terminal deletion, in all cases). They also noted that this cytogenetic profile is found in approximately 3% of uterine leiomyomas. Three attempts to demonstrate cytogenetic abnormalities in our case were not technically successful. Future studies in this area would be of great interest. This case study highlights a rare case of a cystic pulmonary nodule of benign metastasizing leiomyoma which can offer radiologic, clinical, and histologic challenges in differential diagnosis. Clinicians, radiologists, and pathologists should consider this entity in asymptomatic patients presenting with multiple PET-negative pulmonary nodules.

Very few cases have been reported in which the production and secretion of intact PTH by a non-parathyroid tumor has been authenticated. This paper describes the case of a 73 year old white female with a clinical and biochemical profile characteristic of primary hyperparathyroidism. Sestamibi scan and comprehensive neck ultrasono-graphy failed to localize a cervical lesion. Because the clinical manifestations were striking, neck exploration was performed. Dissection of the central compartment identified a lesion. PTH levels dropped to normal within ten minutes after its removal. Intraoperative parathyroid hormone assays facilitated the successful surgical removal of the lesion. Pathological examination yielded a diagnosis of a neuroendocrine tumor. These results document the ectopic production of intact PTH by a neuroendocrine tumor and present a novel neoplastic cause of primary hyperparathyroidism. This is the second report of an ectopic neuroendocrine tumor in the head and neck which secreted intact PTH.

Objective . Black thyroid is a rare pigmented change seen almost exclusively in patients upon minocycline ingestion, and the process has previously been thought to be generally benign. There have been 61 reported cases of black thyroid. We are aware of 13 cases previously reported in association with thyroid carcinoma. This paper reports six patients with black thyroid pigmentation in association with thyroid carcinoma. Design . The medical records of six patients who were diagnosed with black thyroid syndrome, all of whom underwent thyroid surgery, were reviewed. Data on age, gender, race, preoperative fine needle aspiration biopsy (FNA), thyroid function levels, and pathology reports were collected. Main Outcome . The mean age was 60 years. There were 5 females, 4 of whom were African American. All patients were clinically and biochemically euthyroid. Black pigmentation was not diagnosed in preoperative FNA, and only one patient had a preoperative diagnosis of papillary thyroid carcinoma. The other patients underwent surgery and were found to have black pigmentation of the thyroid associated with carcinoma. Conclusions . FNA does not diagnose black thyroid, which is associated with thyroid carcinoma. Thyroid glands with black pigmentation deserve thorough pathologic examination, including several sections of each specimen.

A 47-year-old man was referred to a pulmonary clinic with a 4-year history of dyspnea, productive cough, weight loss, low-grade fevers, night sweats, and occasional hemoptysis. During those 4 years, the patient had undergone multiple serologic, sputum microbiological, and radiographic studies, as well as a bronchoscopy examination; 4 months prior to referral, due to worsening in symptoms, video-assisted thoracoscopic surgery (VATS) for right lung biopsy was performed. Due to the patient's clinical symptoms and abnormal radiographic findings, he had received multiple courses of antibiotics, including 2 months of RIPE therapy (ie, therapy with isoniazid, rifampin, ethambutol, and pyrazinamide) for undocumented tuberculosis, without any significant response. His medical history was positive for COPD, chronic sinusitis, recurrent pneumonias, gastroesophageal reflux disease, hepatitis C, and alcohol abuse. He did not have any history of uveitis, cervical/lumbosacral stiffness, or musculoskeletal pain. His family history was not contributory. His surgical history was remarkable for a VATS procedure for right lung biopsy. His medication list included formoterol, albuterol, pantoprazole, diazepam, and tiotropium. He smoked two packs of cigarettes a day for 30 years. The patient was from rural Mississippi, and he reported no history of travel outside of this area. He was a farmer but had been unable to work during the last 2 years due to his poor health status.

Papillary angioendothelioma is a rare, low-grade neoplasm of lymphatic channels that usually presents intradermally. We report the case of a 6-year-old girl with isolated splenomegaly and symptoms of early satiety and weight loss, whom was found to have a splenic papillary angioendothelioma. Preoperative abdominal computed tomography scan showed an irregular, heterogeneous mass; a tagged red cell scan ruled out a hemangioma, whereas a positron emission tomography scan showed mildly increased uptake. Subsequent surgery and pathologic assessment revealed a papillary angioendothelioma (Dabska tumor) within lymphatic spaces. The child has no evidence of recurrence or metastases 1 year postoperatively.

Multilocular renal cyst is an uncommon lesion of controversial histogenesis. The authors report a case of renal multilocular cyst with müllerian (ovarian)-like stroma. We suggest that this finding would support a dysontogenetic origin for the lesion.

Giant cell interstitial pneumonia is a distinctive and uncommon form of interstitial pneumonia. It is distinguished by the prominence of large, actively phagocytic alveolar giant cells of histiocytic origin in the presence of chronic interstitial pneumonia. Multinucleated type 2 granular pneumocytes are also identified. The multinucleated cells lack viral intranuclear inclusions of the type seen in measles pneumonia. Giant cell interstitial pneumonia may be idiopathic or it may occur with occupational exposure to hard metals or cobalt. We report this case to give recognition to an uncommon interstitial pneumonia.