Previous Pathology Case Challenges

A 37-year-old woman presents with recent onset of flank pain and a 2-day history of gross hematuria. Urinalysis shows 4+ red cells and red cell casts but no epithelial cells.

A 35-year-old Caucasian man presents to his physician complaining of a painless right testicular mass that has been growing over the last 3 months.

A 92-year-old woman presents with abdominal fullness and epigastric pain. She reports a 40-pound weight loss over the past year.

A 38-week-gestation boy was born to a 38-year-old mother. Pertinent physical exam findings included up-slanting eyes, webbed toes, and a murmur consistent with a ventricular septal defect.

A 22-year-old G2P1 woman in labor is admitted to a local hospital. She informs the admitting physician that based on prior ultrasound evaluations her fetus exhibits findings consistent with intrauterine growth restriction.

A 45-year-old construction worker sustains a superficial laceration to his arm at his worksite and does not receive immediate medical attention. Several weeks later he develops generalized erythema and discoloration of the upper extremity skin.

A 13-year-old boy presents with a soft tissue mass in the posterior aspect of the right knee. On palpation the mass is round and hard measuring 5.0 cm in diameter. Imaging studies include an ultrasound demonstrating a hyperechoic shell with a hypoechoic center. Gross examination shows a round mass with a calcific outer rim and an edematous fibrous appearing core.

A 68-year-old woman presents with headache and seizures of recent onset. Computed tomography (CT) of the head shows a 4.0 x 3.0 cm contrast-enhancing, well-defined, left parasagittal mass compressing the parietal lobe. The mass is resected and on gross examination shows a firm, well-demarcated tan-white tumor attached to a small segment of dura.

A 41-year-old woman presents with a one-month history of vague abdominal pain. Physical examination reveals mild right-upper quadrant tenderness. Computerized tomography (CT) imaging shows a solitary 12 cm cyst in the left lobe of the liver. No other imaging abnormalities are present in the chest, abdomen, or pelvis. Her serum alpha-fetoprotein, CEA, and CA19-9 are within normal limits.

A 71-year-old man expires in a nursing home and an autopsy is performed. At autopsy, he is found to have a strangulated segment of jejunum within an incisional hernia with resulting sepsis. In addition, an enlarged thymus weighing 30 grams is identified. Representative tissue is obtained from the enlarged thymus.

A 77-year-old man presents with a 5.0 cm nodule on computerized tomography examination. The nodule is partly solid and partly ground glass, located in the periphery of the left lower lobe. The patient has a history of 2.0 cm poorly differentiated, non-small cell carcinoma in the right-upper lobe, which was resected 4 years prior. Gross examination of the left-lower lobectomy specimen reveals an ill-defined, solid mass puckering the overlying pleura. The cut section shows a tan-white, gelatinous, mucoid, lobulated mass measuring 5.0 cm in greatest dimension. Representative sections are submitted for microscopic sections.

A 65-year-old man presents with intense abdominal pain and constipation. Computed tomography (CT) scans reveal a single large abdominal mass involving the transverse colon as well as abdominal lymphadenopathy. After segmental resection of the transverse colon, a single mass is identified, with a fleshy, tan appearance on cut sections. Immunohistochemistry shows that the lesional cells express CD20, PAX5, CD10, BCL6, BCL2, and kappa light chain, but are negative for lambda light chain, CD5, BCL1, EBER, and cytokeratin AE1/3. The proliferative rate by Ki-67 is approximately 50%. No follicular dendritic meshworks are seen by CD21. Molecular testing is positive for t(14;18), but <em>MYC</em> gene rearrangements are not identified.

A 24-year-old woman with no significant medical history presents with vague persistent abdominal discomfort. On computed tomography (CT) imaging a 5.3 cm, solitary, well-circumscribed liver lesion with a central area of scarring is identified within the left hepatic lobe. A resection of the lesion is performed.

A 30-year-old woman presents with rapid onset of vomiting, abdominal pain, and distention. Radiologic imaging reveals a 20 cm cystic mass causing bowel obstruction due to volvulus. The patient undergoes emergency surgical removal of this large mass, with small-bowel resection and end-to-end anastomosis.

A 47-year-old man presents with a slowly growing asymptomatic solitary 6.0 cm posterior neck mass that has been present for several years. The mass is mobile upon palpation and appears superficially centered in the subcutis. The mass is surgically excised to reveal a well-circumscribed tumor with a translucent, tan cut surface. Immunohistochemical stains show the tumor cells to be positive for CD34, but negative for S100, actin, and desmin.

The patient is a 66-year-old man who presents for combined heart and liver transplantation. The patient was in his usual state of good health until two years earlier, when he experienced a gradual onset of shortness of breath. Cardiac workup revealed biventricular wall thickening, wall motion irregularities, decreased ejection fraction, and congestive heart failure. A cardiac biopsy was performed, which triggered additional clinical testing and a diagnosis. He developed arrhythmias, necessitating placement of a biventricular defibrillator, followed by progressive decline in his cardiac status, eventually leading to transplantation. Hepatic workup showed only changes of congestion related to cardiac failure.

A 24-year-old woman presents with abdominal fullness and a palpable mass on bimanual exam. Imaging reveals a solid mass in the left ovary. Non-enhancing magnetic resonance imaging (MRI) shows high signal intensity centrally with a decreased peripheral signal. At laporatomy, a grey-white bosselated mass with a smooth surface is removed by enucleation. The tumor is yellow-white on sectioning and is largely solid with a few small cystic areas. It measures 12 x 10 x 7 cm in maximum dimensions.

A 39-year-old woman presents with right upper quadrant pain. After a thorough examination abdominal imaging is performed. She is found to have gallstones and an 8.0 cm right lobe hepatic mass. No central scarring is noted and the background liver is noncirrhotic. Her serum alpha-fetoprotein (AFP) levels are normal. Additional questioning reveals the patient is using oral contraceptives. After consultation she undergoes a partial hepatectomy. Accompanied is an H&E slide from the resection specimen. A reticulin special stain shows intact hepatic architecture with no thickening of the cell plates (greater than or equal to 3 cells thick). Immunohistochemistry for liver fatty acid-binding protein (L-FABP) and beta-catenin (nuclear) are negative in the hepatocytes of the lesion.

A 57-year-old woman who has never had a colonoscopy presents with a pelvic mass and an exploratory laparotomy is performed. Intraoperative findings are significant for omental caking, moderately enlarged ovaries, and peritoneal studding including the fallopian tubes, rectosigmoid soft tissue, and right pericolic gutter. Optimal debulking surgery is performed. Multiple firm, tan-white nodules are present in the omentum, measuring up to 17.0 cm in greatest dimension. The glass slide is a representative section of the omentum; however similar microscopic findings are present in the peritoneal biopsies, the surface of bilateral ovaries, and the serosa and mucosa of bilateral fallopian tubes.

A 74-year-old man presents with crampy abdominal pain and small bowel obstruction. At surgery, numerous masses are identified in the distal small intestine and liver. The patient subsequently expires, and undergoes an autopsy.