• ELLIS FISCP.EL STATE CANCER CJ':N'J'ER ORJIL PI\THOLOCY SF.MINAR 184 O.P.S. NO. 84-235 MI\Y 22, 1984

CASE' BISTORI£5

tl (583-15836) COntributed by Noel Weidner, M. D. , Pathologist, The University of Iowa, Iowa City, Iowa. Hypopharyngeal area in a 12 year old boV• The tumor was di~fus~y infiltrating the regional muscles. "

CAS£ 12 (584-36874) Contributed by Larry Mosby and William c. BuCher , M.D. Boone Hospital Center, COlumbia, Mo. 19 year old caucasian female admitted to Boone Hospital Center because of a nodule i n the region ot the left parotid. A parti al parotidectomy was performed measuri ng 6 x 4.5 x 2' cm i n greatest dimension. On section there was a tan, lobular circumscribed so~t nodule 2.2 x 1 . 8 em.

OSP. 13 (82-1411 a or 82- 1411 b) COntributed by Steven D. Vincent, D.D.S., & Harold L . Hammond, D.D.S., M.S., Department of Oral Patholoqy ~Diagnosis, COllege of Dentistry, university of Iowa , Iowa City, Iova. - A 31 year old Oriental female states that two I , weeks ago she burned her hard with hot coffee. Subsequently she noticed a swelling of t he area. The lesion is not particularly tender. It is about 1.5 em in diameter and exhibits a ~· small central ulceration. Radiographic findings are non-contributorY• The remainder of the physical examination and history are unremarkable exc ept that she reports excision of a node one year ago. (S84-332) COntributed by Fre' d P. Handler, M.D., St. Mary's Health Center, Je~ferson City, Mo.

A 58 year old mal~ admitted to St. Mary's Health Center, Jefferson City with the main complaint ot a nodule of the right neck in the r egion of the parotid gland. The nodule was excised.

CASE t S (584 -37462) Contributed by Thomas COyle, Gerald Arthur and William Bucher, Boone !lospit<11 Center, Columbia, Mo . A 71 year old· caucasian female developed a nodule in the left submaxillary gland of undetermined duration. An excision was performed. O.P.S. NO. 84-235 CASE HISTORIES CONTINUED

CASE 16 (84 -299) Contributed by ors. Charles Dunlap and Bruce Barker, Department of Oral Pathology University of Missouri-Kansas City school of Dentistry. A 62 year old female had a 2.0 em white :Lesion on the ende-ntulous mandibular alveolar mucosa, duration unknown. CASE t7 (84-373) Contributed by Drs. Charles Dunlap & Bruce Barker, Depattment of Oral Pathology, University of Missouri- Kansas City school of Dentistry.

A 69 year old female who exhibits a diffuse redness of the with scattered clinical which will not rub off. Culture for fungus was negative. She is 6 months post radiation therapy to the nasopharynx and larynx for . The is extremely sore and has been so ior at least 3 months. l\ blind biopsy of the buccal mucosa was taken (your slide).· Past medical history reveals radiation to the pituitary 50 years previously for~ amenorrhea (unknown amount). A recent history of iron deficiency, anemia, l aryngectomy-for ca r cj: 6 months ago, and colon l resection for carcinoma 3 months a go. I CASE 18 (84-430) I Contributed by ors. Charles Dunlap & Bruce Barker, Department of Oral Pathology, University of Missouri-Kansas City School of Dentistry.

A 6 year old boy has a history o f four recurrences of painful tongue ulcers since October, 1983. ~ photo of the most recent episode is enclosed. The posterior was approximately 1.5 em, shallow and very painful. The anterior left lateral tongue mucosa exhibited a f inely granular, red appearance. Your slides are identified as (A) anterior a nd P (pqsterior) lesions. Viral and fungus cu ltures were negative and bacte.rial cultures show alpha hemolyt ic streptococcus, normal floJ'a. His 9en·eral health was good and • t here was no fever. CASE 19 (84-321) Contibuted by John Andelin and carlos Perez-Mesa, M.D., Ellis Fischel State Cancer Center, COlumbia, Mo . A 72 year old white female referred from a hospital in Las Vegas, Nevada with a two and a half year history of left facial edema and left oropharynx mass. Extensive workup at the initial presentation revealed a left maxillary sinus mass and multiple O. P.S. NO. B4-235 CASE HI STORIES CONTINUED

t 9 biopsies were consistent with chronic inflammation. LOst to follow up sho present ed to Ellis Fischel State Cancer Center with massive left facial edema and a left oropharynx mass which was biopsied. x-rays and photographs are included.

- UNIVERSI1Y OF MINNESOTA DMsiOn ar Suralcal Patholo!lr l5TI TWIN CinES DepaJtmeM oll..ll>o<&IOry MedioO>o and Palhology Box 76, Mayo Memoriol BuildOlg MinnNpob. IJ...... 55455 (612) 373-8760 Hay 3, 1984 or. carlos Perez-Mesa Department of Pathology Bllis Pischel State Cancar Hospital Columbia, MO 65201

Dear Carlos:

These are my diagnoses for the oral Pathol ogy Seminar '184.

1- Pibroeareoma vs. monophasic synovial sarcoma.

2- Typical acinic c ell carcinoma.

3- Inflammation with ~ialo metaplasia. 4- Benign mixed tumor vith predominance of myoepithelial ("hyaline") cells. 5- Anaplastic (solid) variant of . 6- I favor adenoid over warty dyskeratoma. 7- Squamous carcinoma in situ (despito the maturation), with pagetoid features and possible microinvasion.

8- Non- specific u lceration (rule out Behcet's syndrome). 9- I favor malignant lymphoma with artifactual clear changes in the cytoplasm, but I would like to see PAS and mucin s t ains .

Best personal regards, ~

Juan Rosai, M. D. Pr ofessor, Laboratory Medicine and Pathology Director of Anatomic Pathology JR/DMP

HEALTH SCIENCES ELLIS FISCHEL STATE CANCER CI!HTER ORAL PATHOLOGY SEMINAR 1M (~23~ May 22,19M

"'FFICIAL DIAGNOSIS" ·- CUe I I (S&).I}336) SARCOMA, PROBABLE MONOPHASIC SUB TYP£ Contributed by Noel Weidner, M.D., Univ~rsity of Iowa

A slight majority of the consultants interpreted the lesion as fibromatosis. WHITE from the Univ~rsity of K~ntucky in Lexington, WEATHERS from Emory, NELSON, FINXELSTEIN, VINa!HT and HAMMOND from Iowa, BATSAKIS from M.D. Anderson preferred asgressive fibromatosis. A few comments at random: HANSEN from the University of California, San Francisco: "We had a good deal of difJiculty with this case determining whether it was reactive or a low grade sarcoma. The consensus was that it was most likely of librous origin and therefore an aggressive fibromatosis mjght be an appropriate term. SHAFER from Indiana: "Aggressive fibromatosis vo. neurofibroma. CNEPP from St. Louis University offered: "Aggressive libromatosls vs. a "tumefaetive fibroinfJammatory lesion." WALDRON from Washington University: "I believe this is something in the fibromatosis-inflammatory tumor type group - ~ not appear histologically to be malignant.• ABRAMS from USC: •Some areas look endothelial and some neuraL I will senle on neurofibroma." The diagnosis of fibrous hlstocytoiJla was Iavored by HORl from Elkins, West Virginia and SPRAGUE from Nebraska. LeGAL from Strasbourg preferred: "Proliferative myositis." AUPDEMORTE from the University of Texas in San Antonio: "Intermuscular hemangioma, capillary type-previously operated-gel foam ? - sclerosing agents or XRT." . BARKER and DUNLAP from the University of Missouri, Kansas City: "Fibrosarcoma - some areas of the tumor look awfully neural. We cannot completely rule out neural origin." TARPLEY and CORIO from Nit{: "Small cell malignancy - probably mesenchymal origin. Rule out rhabdomyosarcoma." FAYE from l()th Medlcal Laboratory: "Rhabdomyosarcoma.• HYAMS and HEFFNER from AFIP: •SarC001a, favor fibrosarcoma, cannot rule out malignant peripheral nerve neoplasm.• ROSAI from Minne-sota: "Fibrosarcoma versus monophadc. synovial sarcoma.• An additional commentary from Or. Weidner, tl1e contributor: "In my opinion fibrosarcoma is the main differential and difficult to rule out by purely microscopic features. EM appeared to suggest a fibroblastic tumor, but lmmunoperoxidase studies with anti-keratin were Interpreted as positive. The patient received radiation therapy followed by resection. The tumor w~ clearly malignant but maintained the same spindle cell morphology. A biphaslc component was.not obser'ved. PAGE 2 of "OFFICIAL DIAGNOSIS"- OPS84-23}

Casefl2 (S84-36974) Contributed by Drs. Larry Mosby and William C. Bucher, Boone Hospital Center, Columbia, Missouri

It was the monolytic consensus that ·this represented an acinic cell carcinoma, (A lonely dissenter, Or. X) thought this could possible repre.sent a metastases ~ from adrenal or ovari~n origin."

Case II 3 (S82-l~ll A or B) SUGGESTIVE OF SENJGN LYMPHOE.PITHI!LIAL L£SION Contributed by Steven D. Vincent, D• .D.S. and Harold L. Hammond, D.D.S., M.S., University of Iowa. () IV~ 1 The majority of tHe consultants t~nd to agree that the. lesion is benign althoug~ i in some cases this· diagnosis is established with caution. A few commentari~;. WALDRON from Washington University: ''Benign Jymphoepithelial lesion. I i always worry about these lesions but the infiltrate seems to be.sparing the duets and myoepithelial islands are present. I wonder if the neck node a year ago was l also a BLEL - the infiltrate· is largely lymphocytic and 1 .don't see any highly atypical cells." WEJ\ THeRS from Emory: ''The presentation is unusual but I think that this probably represents a beh.i.gn 1)'111phoepithellalle.s.ion.11 HENRY AZAR from the VA in Tampa: "Lymphoid infiltrate in minor salivary glands, probably consistent with Sjogren's disease of pseudolymphoma." I caMot make a definite diagnosis of Jymphom.,...a .on this matt!:riaV' GNEPP from St. Louis l!niversity: "Lymphoepithellal ·Jeslon with marked I lymphoid atypia; can't make a diagnosis of lymphoma, but 1 am concerned about , ~~PDI!MORTE from Texas: ''Lymphoeplthelial (epimyoepithelial ; islands are rare in minoT g1gnds). Rule out focus resolving necrotizing 1 sialometaplasia. Is this a representative biopsy-no ulcer. Why was neck node removeC:I?" ROSAI from Minnesota: ••Inflammation with sialometaplasia." SHAFER from Indiana: "Benign lymphoepithelial lesion. We have never seen ' epitheU~J i~l.ands in any of our palatal lymphomas." BARKER and DUNLAP: "Benign lymphoepithelial lesion_- on such a small biopsy we would be reluctant to completely rule out the possibility of a lymphoma,• There were others; however, with dissenting views: HANSEN from San Francisco: "Atypical lymphoproliferative disease, most likely a I ymphom'a.• EUSI!& from Universlta Di Bologna: "Malignant lymphoma, diffuse, mixed small and large cell." HYAMS and HEPFNER from AFlP: "Atypical lymphottistocytic infiltrate suggestive of 1)'1!1phoma." SPRAGUE from Nebraska: "Malignant lymphoma." WHITE from University of Kentucky: "Malignant lymp,homa1 predominately ~mall cleaved follicular center cell type." BATSAKIS and LUNA from M.D. Anderson diagnosed the lesion as: "lymphoma." ABRI\MS from USC stated: "lymphoproliferative disease with some suspicions for lymphoma." PAGE 3 of "OFFICIAL DIAGNOSIS" - OP$84-·235

Case /14 ($84-332) Contributed by Fred P. Handler, M.D., Jefferson City, Missouri

Total and complete agreement .. Comments at random: RHORER, YOUNG, and BLASS from Oklahoma: "Pleomorphic adenoma.. with· predominane<: of myoepithelial ceUs." Another sole dissenter calle

Case# 5 (584-37462) ADENOCYSTIC CARCINOMA. SOLID VARIANT -?l{kwy Contributed by Thomas Coyle, Gerald Arthur, and William Bucher, Boone Hospital Center, Columbia, Missouri

Unanimous agreement that the lesion is malignant-with only variations perhaps in sematics and maybe histogenesis. A few samples: WEIDNER 1rom IOWA: "l favor a di~gnosis of poorly differentiated carcinoma.. In my seactions t.here ·seems to be a few due.s as. to the appropriate -subclassification of this carcinoma; however, I dld coMider a high grade adenocystic carcinoma. A high mitotic count, invasive stroma pattern, ·and extensive neural invasion suggests aggressive behavior." · WALDRON from Wasi)il)gton· University: " oi salivary gland origin - I still get confused on the many subclassifications of salivary gland ." HAMl,IQN, .NELSoN, FINKELSTEIN, and VINCENT from the University of Iowa: "Adenoc:Ystic ~arcinoma." EUSl!Bt' from Bologna offered: "Adenocystic carcinoma, solid type." The di"agnosis of anaplastic (solid} viriant of adenocystic carcinoma was the most popular diagnoSis. Some con~rn that the lesion could be metastatic from only two of the consultants. BATSAKIS and LUNA from M.D. Anderson: "terminal duct carcinoma." ~

Case# 6 _(84-2,,) SQUAMOUS CELL.CARCINOMA, ACI\NTHOLYTI~ TYPE ~/\ Contributed by Dr.s. Dunlap- and -Barker. University of Missouri, Kansas City, Missouri

This is a cqntroversial lesion. The majority of the co_n.sultanti preferred the diagnosis of "Warty dyskeratoma'• (~caJJ ed isolated Oarier's disease). FoUowing is an example of opinions: SHAFER from Indiana: uwarty dyskeratoma versus vegetans VS-. adenoid $quamous carcinoma. Very strange.•, AZAR from Tampa: "Probably a rare case of warty dyskeratoma or "focal . acantholytic . I was tempted to call it acantholytic squamous ceU carcinoma." ABRAMS lrom IJSC: "Warty

Continuation of case , 6 BARKER and DUNLAP commented: "Squamous cell carcinoma, acantllolytic type - while warty dyskeratoma was considered In the differential diagnosis, the presence of dysplastic squamous cells between deep bundles of skeletal muscle fibers as presented at the conference suggests a matl.gnant process. We do not feel the presence of these nests were due to tangential section. FO!.l.OW-UP: The patient was referred to EFSCC where I reviewed tile sUdes. After a prolonged and agonlxlng reappraisal Drs. Barker and Dunlap convinced me to change the diagnosis from warty dyske ratoma to adenoid squamous cell carcinoma. The patient had are-excision of the area; however, the lesion had been already removed during the initial surgical process.

Case I 7 (8'1-373) MODERATE TO SEVERE DYSPLASIA, DIFFUSI! Contributed by Du. Cllarles Dunlap and Bruce Barker, Unlv. of Missouri, Kansu City, Mo.

All consultants acknowledged the abnormal mucosal changes, however, with varying degrees. At random, sample selection of opinions: . ROS/\.1 from Minnesota< "Squamous carcinoma In situ (despite the maturation) wlth pagetoid features and possible microinvasion". Yfl!lDNER from Bowman Gray Medical Schooh "I belleve a true squamous dysplasia is present which Is predominately basally located. The history suggests the possibility of radiation Induced disease, but from the history, lam not sure II this area was exposed. The patient-appeared to have a cancer diathem and the dysplastic changes may not be related to radiation therapy at all". LUNA a: 8ATSAKfS from M.O. 1\ndenon and HORJ from Elkins, Virginia prefer hyperplasia of basal layer. ROHRER, YOUNG a: GLASS from' Oklalloma: "Moderate to severe clysp.lasla. This snould be managed like carcinoma in situ even tllough the changes are not involving the full th.ickness of the epithelium... WEATHERS from Emory: "Severe dysplasia. Is this an example of Plummer· Vinson syndrom~? LEGAL from Strasbourg preferred: "Erythroplasia of Queyrat. NELSON, FINKELSTEIN, VINCENT a: HAMMOND from Iowa: "Marked epithelial dysplasia versus squamous cell carcinoma. HYAMS a: HEFFNER from the F!P: "Bas alar area dysplasia suggestl.ng early squamous cell carcinoma. FAY a: STAFF from lOth Medical Laboratory: "Basal ceiJ dysplasia due to radiation? Does thi.s represent multifocal dysplasia-neoplasia as seen in some cases a laryngeal carcinoma-one of our staff mentioned the possibility of a melanotic melanoma (he or she will be nameless unless they ~urn out to be correct). EUSEBI from Bologna: "Dysplasia. The lesln looks like Bowenold actinic of the skin. DIIRKER .t DUNLAP Issued the following comment: "We ar~ uruure u to the etiology of this diffuse precancerous lesion. The changes present do not appear to be characteristic of the previous history of radiation. Tnere may be some relationship to the history of iron deficiency anemia as per the Plummer-Vinsoo syndrome. • Since the histories were mailed the patient developed multiple metastases to the cervical lymph nodes with a squamous c ell carcinoma of the nasopharynx. PAGE $of ''OFFICAL DIAGNOSIS" - OPS84-23$ CASE. I 8 (84-430) NONSPEClFIC ULCERATION-ETIOLOCY UNKNOWN t J 11- f!N.. Contributed by Drs. Dunlap at Barker, University of Mo-Kansas City School of Dentistry.

ABRAM from USC commented: "Compatible with . Does not seem to be severe enough for the diagnosis of Ly.,U's disease. I suppose a staphylococcal scalded skin syndrome might be considered. 1\ZAR from Tampa: "Liquefaction necrosis of •quamous epithelium with mixed leukocytic reaction, suggesting erythema multl!orme. 1fHJTE from K"ntucky: "Ulceration and necrosl•. Would evaluate patient for medications, placement of toxic chemicals on tongue and eryth.,ma multiforme.• WEATHERS from Emory: "The section (A) Is nonspecillc epithelial hyperplasia and edema with some surface organisms that suggest that this may be morsicatio linguorum. Section B appears to represent a deep nonspecific ulcer which is also consistent with a factial injury putting the A at B together. The white counts might be done to rule out a neutropenic ulcer." tfALORON from Washington Univei'Sity: "I am also having a bad time with this case in correlating the history, excellent clinical photo and the histology. The anterior biopsy (slide A) shows an unusual epithelial necrosis involving the upper two-thirds of the epithelial laye.r and sparing the lower one-thlrd. This patt"m reminds me of some form oJ contact stomatltis.. The pattern ls also somewhat like the findings in erythema multiforme of the oral mucosa but the clinical situation doesn't s..,m rigl'ot for this. The posterior biopsy bllde B) shows a chronic ulcer with· the process extending to involve muscle. l've seen this kind of a reaction In major aphthae but the clinical photo and history don't really sound like typical Sutton's disease. I am stuck." AUFDEMORTE lrom San Antonlo: W ?Any other cutaneous, ocular or g

More than half of the consultant$ int.,rpreted the lesion as a non-Hodgkin's lymphoma of various typ

Follow-up: The lesion was cla.uWed as diliuse lymphoma of the lymphocytic, well dilferentiated type with prominent plasmacytoid features. The electrophoretic: show a prominent monoclonal lgM paraprotein. The lesion ..,as considered of a malignant lymphon!ticular process to represent an expression of Walstrom's macroglobulinemia. Bone marrow aspirate shows plasmac:ytosls without atypical features. In addition, ~here was also Infiltration ln the bone marrow by a lymphoma with the same c:ytological features as in left maxillary sinus mass. The patient was treated with radiation therapy with a dramatic reduction in the size of the lesion (see accompanying photograph). Subsequently she received chemotherapy including cytoxan, vincristine, proearbozine and prednisone. She i.s still presently under observation after the completion of the treatments.