A 66-year-old Caucasian female with a 40-pack-year history of smoking and chronic obstructive pulmonary disease presented for follow-up of synchronous multiple primary lung cancers: Stage IB left upper lobe adenocarcinoma and Stage IA right middle lobe (RML) squamous cell carcinoma. The patient was treated with left upper lobectomy and RML pulmonary wedge resection 5 years prior. Surveillance chest computed tomography showed an increase in the size of the subcarinal lymph node and right lymph node conglomerate encasing the right upper lobe pulmonary artery, consistent with metastasis. Fine-needle aspiration of level 4R lymph nodes was performed. Histology and immunohistochemical staining confirmed the diagnosis of small cell carcinoma. Consequently, the patient was placed on cisplatin/etoposide combination chemotherapy.

Objective To identify clinical/laboratory factors associated with folate deficiency in tertiary care patients. Methods We reviewed the medical records of 1019 patients with serum folate <7.0 ng/mL, 301 patients with serum folate of 15 ng/mL, and 300 patients with serum folate > 23 ng/mL. Results Serum prealbumin levels were subnormal in 54.8% of patients with serum folate <7.0 ng/mL. Vitamin B12, hemoglobin, and serum albumin levels were significantly lower in the <7.0 ng/mL folate group. In 62.4% of patients with serum folate <7.0 ng/mL, 1 or more markers of malnutrition were present. The low-folate group had a significantly higher prevalence of gastrointestinal (GI) disorders, sepsis, and abnormal serum creatinine level. There were no significant differences in the 2 groups regarding diabetes; behavioral/neurological disorders, including drug and alcohol abuse; bariatric surgery; or a diagnosis of malnutrition. The average body mass index (BMI) for the <7.0 ng/mL and 15 ng/mL folate groups was significantly different (28.89 and 28.31, respectively), although the difference does not appear to be clinically meaningful. Conclusions The prevalence of folate deficiency depends on what is considered a normal serum folate level. Approximately 10% of tertiary-care patients have levels <7.0 ng/mL and exhibit other markers of malnutrition. It is recommended that patients with GI disorders, chronic kidney disease, and sepsis be routinely tested for serum folate levels, before administration of vitamin supplements. Patients with serum folate levels <7.0 ng/mL should be evaluated for malnutrition, despite BMI > 25. Folate supplementation should be administered only after excluding coexisting vitamin B12 deficiency.

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Background: Clear cell odontogenic carcinoma (CCOC) is a rare malignant odontogenic epithelial neoplasm of the jaws. It is composed of irregular nests of clear to faintly eosinophilic cells resembling clear cell rests of primitive dental lamina and an intermixed hyalinized fibrous stroma. Most cases occur in the 5th and 6th decades of life, with a female predominance. The mandible is affected more than the maxilla. Clinical features vary from asymptomatic to non-specific pain, ill-defined radiolucency, root resorption, and sometimes soft tissue extension. Histology varies from bland to high grade. CCOC demonstrated a significant tendency to recur. Metastasis typically involves regional lymph nodes, which haves been reported in 20–25% of cases. Pulmonary metastasis rarely occurs. Differential diagnoses are broad and include odontogenic, salivary, melanocytic, and metastatic neoplasia. CCOCs are positive for cytokeratins, mainly AE1/AE3 and CK19. Most cases show EWSR1 rearrangement and rarely, the BRAFV600E mutation. Design: Patient charts were reviewed at our institution. A total of three cases were found in electronic medical records, which were diagnosed as clear cell odontogenic carcinoma over a period of six years (2014–2019). Patient charts were reviewed for medical history and radiology data. The pathology slides were reviewed by one or more faculty members. Results: We present three cases of CCOC, ranging in age from 40 to 69 years (two women and one man). Two cases involved the maxilla and one involved the mandible. Two presented with painful swelling and one with mass recurrence. Radiography results show that two had poorly defined radiolucent lesions, and one was heterogeneous with a small nodule projecting into the maxillary sinus. Histological examination revealed an epithelial neoplasm composed of irregular sheets, cords, and nests of polygonal cells with central hyperchromatic, mildly pleomorphic nuclei surrounded by clear to pale eosinophilic cytoplasm, with occasional mitotic figures. The tumor had infiltrated the bone and soft tissues. Two cases were immunopositive for CK5/6 and one case was positive for p63 and CK19. Interestingly, the eosinophilic dentinoid matrix interspersed among tumor cells in one case was consistent with its odontogenic origin. Histochemical staining showed PAS-positive and diastase-labile intracytoplasmic material consistent with glycogen. Conclusion: Our study highlights the potential diagnostic significance of dentinoid (although reportedly seen in only 7% of cases), along with CK5/6 immunopositivity, in supporting the histologic diagnosis of CCOC among a variety of neoplasia in its differential diagnosis.

Multiple primary lung cancers (MPLC) are a rare occurrence and have 2 formssynchronous (sMPLC) and metachronous (mMPLC). The sMPLCs are physically distinct with different histological subtypes. If they are the same subtype, they must be in different lobes of the lung, originating from carcinoma in situ, and no tumor in common lymphatics and extrapulmonary metastases. The mMPLCs tumors must be histologically different or if they are histologically identical, there must be a >2 year cancer free interval, originate from carcinoma in situ, and second cancer must be in a different lobe or lung with no carcinoma in the common lymphatics and no extrapulmonary metastases. mMPLC is common and secondary to treatment of initial lesions. Tobacco smoke may also create a "field effect" in which multicentric lung cancers manifest more frequently.