To the Editor A 65-year-old woman with a positive family history for breast cancer presented with the palpable mass in the upper outer quadrant of the left breast. Ultrasonography and mammography revealed an oval, hypoechogenic, sharply demarcated mass, measuring 23 9 14 mm, classified as Bi-RADS 4 (Fig. 1A). A core needle biopsy revealed a cellular spindle cell lesion (AE1/AE3 negative) without prominent atypia and mitotic activity (B3 category, Fig. 1B). The multidisciplinary breast meeting discussed the case and recommended a wide local excision of the mass. Grossly, the 20-mm tumor was well-circumscribed, grayish-white on cut section, without necrosis and hemorrhage (Fig. 1C). Histopathologic examination revealed a well circumscribed, spindle cell neoplasm composed of the cells with mild to moderate atypia and sporadic mitotic activity (up to 5/10 hpf mitotic figures, Fig. 1D,E). An extensive immunohistochemical (IHC) examination revealed only convincing S-100 positivity in about 20% of neoplastic cells (Fig. 1F). All other markers were negative (AE1/AE3, Cam5.2, p63, GFAP, SMA, desmin, CD34, HMB-45, SOX-10) while beta-catenin retained cytoplasmic/membranous expression without nuclear positivity. Morphologic and immunohistochemical findings were consistent with a low-grade malignant peripheral nerve sheath tumor (MPNST). Due to the tumor size, clean margins, and the tumor grade, a close follow-up without further treatment of the patient was recommended (1–3). Additional clinical

Metastases to gastrointestinal tract are uncommon. In particular, metastases to the ampulla of Vater are very rare and may represent a significant diagnostic challenge. Metastases from the uterine cervix to the ampulla of Vater are exceedingly rare and only one case has been described in the available literature. We describe here a second case of metastatic squamous cell carcinoma of the cervix to the ampulla of Vater in a 45-year-old woman. Poorly differentiated squamous cell carcinoma presented as an isolated metastasis to the ampulla of Vater, two years after the initial diagnosis. While the squamous cell carcinoma could occur as primary ampullary carcinoma, albeit very rare, it is necessary to exclude the possibility of metastatic cancer.

Introduction: The haemostatic system can be significantly altered by haematological malignancies and their treatment. Abnormal haemostatic values can be detected in about 50% of advanced disease and these underlie the characteristic thrombotic and haemorrhagic diasthesis seen in these patients. Haemostatic indices in Philadelphia Positive and Negative Chronic Granulocytic Leukaemia Patients were investigated to determine their clinical relevance and possible association. Patients and Methods: Fifteen newly diagnosed Philadelphia positive (ph+ve) and 11 Philadelphia negative (ph-ve) CGL patients were studied longitudinally along with 20 healthy controls. Baseline blood samples were collected and analysed before commencing first cycle chemotherapy and after each successive cycle up to sixth cycle .Samples were analysed for haemoglobin concentration (Hb), leucocytes count (WBC), platelet count (PLT), prothrombin time (PT), activated partial thromboplastin time (APTT), plasma fibrinogen (PFC), and euglobulin lysis time (ELT) using standard techniques. Results were analysed statistically using Student’s t-test. Probability values <0.05 were significant. Results: Ph-ve CGL patients had significantly higher baseline levels of PFC and ELT compared to Ph+ve patients (P < 0.05). Ph+ve CGL patients with complete remission had a significantly lower baseline level of PFC compared to those without remission (P < 0.05). There were no significant changes in PFC and ELT in both groups after the 4th cycle of chemotherapy (P > 0.05). Conclusion: Philadelphia negativity may be a potential risk factor for increased thrombotic tendencies in CGL patients. PFC may be a useful predictive marker of haemostatic activation in these patients.