Eccrine porocarcinoma is an extremely rare malignant cutaneous neoplasm. This tumour has an indolent behavior and misleading clinical diagnosis often leading to a delay in definitive treatment. The definitive diagnosis is made by histopathology since clinical findings often vary. The tumour must be considered in the differential diagnosis of elderly patients presenting with long standing skin lesion with a recent history of accelerated growth rate. Because of its reported high rate of local recurrence, a wide excision of the tumour with clear resection margins is mandatory. Close long term follow up is required. We present herein two cases of eccrine porocarcinoma.

A 35-middle-aged female with history of recent travel to the Indian Subcontinent, presented with features of malabsorption. Blood chemistry revealed low serum albumin and low serum Vitamin B12 levels. Upper gastrointestinal endoscopy was done and was reported as normal. The duodenal biopsy sent for histopathologic examination and is shown (Panel). What is the diagnosis? Answer: refer to page 186

(Refer to page 164) Answer: Giardiasis. The slide shows duodenal biopsy with pear shaped protozoa of Giardia lamblia on the luminal surface of the villi. Giardia lamblia is a pear-shaped, flagellated protozoan that causes a wide variety of gastro-intestinal complaints. Giardia is possibly the most common parasite of humans worldwide and the second most common in the United States after pinworm.

Cervical glial polyps or gliosis of uterine cervix are rare. These are rare polypoidal mesenchymal tumours and usually manifest with vaginal bleeding, post-coital bleeding or cervical discharge. Microscopically these polyps show heterotopic glial tissue with varying degree of gliosis. Immunoperoxidase staining with Glial fibrillary acidic protein (GFAP) confirms the glial nature of the polyp. Controversies remain regarding the origin. Some consider them to be foetal implants following termination of pregnancy whilst others consider them to be metaplastic in nature. We report a rare case of cervical gliosis that was diagnosed after histological examination of the resected specimen in a 32-year-old lady who presented with irregular per vagina bleeding.

Hepatocellular carcinoma (HCC) is the most common primary tumour of the liver. Cholangiohepatocellular carcinoma (CHC) is less common and is a variant of HCC. There are many similarities with HCC with the exception that CHC tend to be more aggressive. We report a case of a 50-year-old man who was diagnosed with CHC and suddenly deteriorated secondary to hepatic tumour rupture. Despite aggressive supportive care, his condition rapidly deteriorated and died. Autopsy showed ruptured CHC.

A 59-year-old Malay man presented with a keratinising lesion over the dorsum of right toe. The resected specimen was an ulcerated necrotic skin covered lesion that measured 5 x 2.5 x 2.5 cm. The cut surface showed blackish powdery granular material embedded in nonviable tissue (Panel A; Haematoxylin and Eosin stain, B; Grocott (Silver) stain and C; Periodic Acid Schiff [PAS] stain). What is the diagnosis? Answer: refer to page 238

(Refer to page 210) Answer: Eumycetoma (Madurella mycetoma or Maduramycosis) Mycetoma is an uncommon localised chronic infection of the skin and subcutaneous tissue that can be due to fungus (eumycetoma) or bacteria (actinomycetoma). It is characterised by a triad of tumefaction, draining sinuses (usually in late stage) and presence of the exudates containing colonial grains. Mycetoma infection is classified based on the aetiological agents and colour of the grains (Refer to supplementary text).

Introduction: We recently developed a scoring system for diagnosis of acute appendicitis. This study prospectively evaluates the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score for the diagnosis of acute appendicitis in patients presenting to the Accident & Emergency department or the Surgical wards with right iliac fossa pain. Materials and Methods: From November 2008 to April 2009, consecutive patients presenting to the Accident & Emergency department or the surgical wards with right iliac fossa pain were recruited for the study. The RIPASA score was applied but the decision for radiological investigations or emergency appendicectomy was made based on clinical judgement. Receiver operating curve (ROC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the new scoring system were derived. Ethical approval for the study was obtained from the Medical & Health Review Ethics Committee. Results: Within six months, 144 consecutive patients with a mean age of 29.5 ± 13.3 yrs were recruited to the study. Ninety-eight patients underwent emergency appendicectomy of which 79 were confirmed histologically for acute appendicitis. The observed negative appendicectomy rate was 19.4%. The optimal cut-off threshold score from the ROC was 7.5, with a sensitivity of 97.5%, specificity of 81.8%, PPV of 86.5%, NPV of 96.4% and a diagnostic accuracy of 91.8%. The predicted negative appendicectomy rate was 13.5%, which is a 5.9% reduction from the observed rate of 19.4% (p=0.3). Conclusion: The RIPASA score is a more suitable appendicitis scoring system developed for our local settings with a population that is reflective of our region in South-east Asia and has high sensitivity, specificity and diagnostic accuracy.
Appendicitis ; Appendectomy ; Diagnostic Techniques and Procedures ; Surgical Procedures, Operative ; Signs and Symptoms

Malignant cystic lesions of the lateral side of the neck are usually due to metastasis and are rarely primary carcinoma. The most common is metastatic cystic squamous cell carcinoma arising from a primary site at the Waldeyer's ring. However, they can arise from papillary carcinoma of thyroid, lung and mediastinum but very rarely from the abdominal and pelvic organs without regional lymph node involvement. Therefore, accurate diagnosis is very important for appropriate management. We report two cases of cystic squamous cell carcinoma of the lateral neck; cystic metastasis from an occult squamous cell carcinoma of the tongue and a primary branchiogenic carcinoma. We emphasize the importance of meticulous search for the primary malignant lesions in cases of cystic carcinoma of the neck.
Branchioma ; Carcinoma ; Cysts ; Metastasis