Nested stromal epithelial tumor is a recently described primary neoplasm of the liver. This tumor is characterized by well-demarcated nests of spindle and epithelioid cells with occasional calcification and bone formation. An association between these tumors and Cushing syndrome has been described. Herein we report a case of a recurrent nested stromal epithelial tumor of the liver in a 17-year-old female with aggressive clinical behavior and an extrahepatic lymph node metastasis. Also, we provide the first detailed clinical, histologic, immunohistochemical, and cytogenetic comparison of the original and recurrent tumors. Initially, the patient presented with Cushingoid symptoms and epigastric pain, radiating to her back. A computed tomographic (CT) scan revealed a large lesion in the liver. After a partial hepatectomy, the Cushingoid features were resolved. A year later, a CT scan revealed multiple lesions within the liver, and positron emission tomographic/CT imaging showed a hypermetabolic lymph node. The patient underwent a cadaveric liver transplant. Histologically, both the original and recurrent tumors had similar characteristics, with different immunoreactivity, correlating with the absence of systemic hormonal symptoms. Electron microscopy of the original neoplasm revealed an abundance of rough cytoplasmic reticulum and mitochondria. No evidence of endocrine differentiation was found. Cytogenetics of the primary tumor was complex with an abnormal hypotriploid karyotype. Our data indicate that patients with nested stromal epithelial tumor of the liver must be carefully followed with imaging to detect hepatic recurrence and extrahepatic metastases.

Mixed acinar‐neuroendocrine carcinoma (MANEC) of the pancreas is a rare tumor. We present two cases of MANEC diagnosed on endoscopic ultrasound (EUS) guided fine‐needle aspiration (FNA). The first patient is a 33‐year‐old male who had a 3.6 cm mass in the uncinate process and liver metastasis. The second patient is a 66‐year‐old male with a 10 cm mass in the pancreatic tail. The FNA smears from both cases were hypercellular with neoplastic cells in loosely cohesive clusters and many naked nuclei. In both cases, the tumor cells were positive for CKAE1/3, synaptophysin, chromogranin, and trypsin by immunohistochemistry. Final diagnoses of MANEC were rendered based on cytological features and immunohistochemical profiles. To date, 44 cases of MANEC have been reported in the English literature, only three of which were diagnosed on cytopathology specimens before surgical resection. Our report adds two more cases diagnosed on cytopathology alone. Herein, we discuss the various cytomorphologic and clinical features of MANEC and present a brief review of the literature. Diagn. Cytopathol.

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Cokeromyces recurvatus is a zygomycetes yeast form that is very rarely detected in Papanicolaou (Pap) tests, in which it typically represents an innocuous colonizer. Its morphology closely resembles that of the better known Paracoccidioides brasiliensis, which can disseminate widely and cause clinically significant disease. We present a case of C. recurvatus detected in a cervical liquid-based preparation obtained from a 38-year old healthy woman. Careful cytomorphologic evaluation, in combination with culture and molecular techniques, was utilized to make a diagnosis and prevent the misdiagnosis of P. brasiliensis.

To the Editor.-In the recent excellent report of mucosal leishmaniasis in Iran by Daneshbod et al 1 the authors correctly note that the diagnostic kinetoplast of tissue amastigotes are rarely identifiable in histologic sections. That is true also for the trypanosomal amastigotes of Chagas disease, which are identical in appearance except that unlike Leishmania they have no predilection for histiocytes. This is demonstrated in the following case of Chagas disease, in which the kinetoplast is clearly seen and differential diagnosis relies on clinical presentation and location of the parasite. The patient, a 56-year-old woman of Bolivian origin, now in New York, underwent heart transplantation for intractable heart failure. The parasite found within the optimally fixed explanted heart is rarely seen in autopsy specimens but was demonstrated here in exquisite detail. Histologic examination of the explanted heart otherwise showed the usual severe chronic myocarditis characteristic of this disease (Figure, 1A), most extensively involving the left ventricle.