Previous Pathology Case Challenges

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.

A 3-year-old girl presents with an incidental posterior mediastinal mass. The surgically resected mass consists of fragmented and emulsified grey-tan, rubbery tissue measuring in aggregate approximately 8.0 × 7.0 × 7.0 cm, and weighing 54 gm. No capsule or areas of necrosis or hemorrhage are identified grossly. Representative sections of the resection specimen are analyzed for histologic analysis.

A 19-year-old man with a one-year history of polycythemia vera (with associated JAK2 V617F mutation) presents to the emergency room after experiencing epigastric pain for several days. The patient reports recent weight loss and dark urine but denies bleeding, bruising or fever. Physical examination is remarkable for mild jaundice, abdominal tenderness, and hepatomegaly without swelling of the lower extremities. Blood work reveals elevated bilirubin of 5.4 mg/dL and transaminases with an AST of 1600 unit/L and ALT of 2100 unit/L. MRI displays moderate-to-large volume ascites, marked splenomegaly and an enlarged liver with hypertrophy of the caudate and left lobes and atrophy of the right lobe. Both MRI and Doppler ultrasound detect occlusion of the hepatic veins. Due to progression of symptoms and persistence of elevated liver enzymes, the patient receives a liver transplant.

The patient is a 21-year-old woman with an approximately one-year complaint of progressive lymphadenopathy and malaise. She noticed a growing firm mass in her right breast, which is not fixed to the overlying skin. At resection, a 6.5 cm ill-defined firm pale mass is noted. Representative sections throughout the entire mass are submitted for histologic analysis.

A 35-year-old woman presents with a 2.5 cm, polypoid mobile mass attached to the left posterior vaginal wall midway between the cervix and introitus. The preoperative clinical diagnosis is vaginal cyst. On sectioning, a well-circumscribed nodule is noted with a smooth, glistening pale-pink to yellow surface devoid of hemorrhage or necrosis. By immunohistochemistry, the tumor cells are positive for CD34, ER and PR and negative for desmin, smooth muscle actin, and S100.

A 54-year-old woman presents with abnormal perimenopausal bleeding and is found to have a 10.0 cm polypoid gray-white hemorrhagic uterine mass filling her uterine cavity.

A 4-year-old girl is being evaluated for a two-month history of back pain unresponsive to conservative therapy. Although routine abdominal X-rays are negative, a CT scan of the abdomen demonstrates the presence of an 8.0 cm right paravertebral mass focally extending into the spinal canal. Surgical resection reveals a 76 gm lobulated tan mass measuring 7.5 × 6.5 × 3.0 cm in greatest dimension and surrounded by a thin layer of connective tissue. The cut surface is soft, tan and uniform, with small areas of hemorrhage. A section of fresh tissue is submitted for an N-myc (MYCN) amplification study. The specimen undergoes extensive sampling.

A 62-year-old woman presents to the emergency department complaining of three days of subjective fevers and chills. Her initial evaluation was notable for both a fever of 100.4°F (38°C) and an 8 cm-wide warm, erythematous, indurated rash on the right calf. The borders of this lesion were ill-defined. On palpation, the rash was tender and without any notable crepitus. The rest of the physical exam was unrevealing. Notably, her white blood cell count (WBC) was elevated to 17,900/µL (normal: 4,000-11,000/µL) with a differential of 86.8% neutrophils (normal: 50-70%) and 8.1% lymphocytes (normal: 18-42%). All other laboratory parameters were within normal limits. Following her emergency department evaluation, the patient is admitted to the hospital in stable condition.

A 79-year-old woman initially presents with facial twitching and is otherwise asymptomatic. Imaging studies performed to rule out the possibility of a stroke reveal a 2.4 cm right parotid gland mass with central calcification and enlarged level II and III lymph nodes. The patient presents again 8 months later with interval increase of her right parotid mass, which now involves the entire parotid gland and measures 7 cm. Additionally, the overlying skin is thickened suggestive of cutaneous involvement, and one of the right level II lymph nodes is now enlarged to 2.0 cm. The resection specimen includes the right parotid gland, levels Ib through IV neck dissection, and a partial auriculectomy. The earlobe, submandibular gland, and jugular vein are unremarkable. The 7.2 × 5.5 × 3.2 cm parotid mass shows gross extension to skin and to the cartilaginous portion of the external auditory canal.

A 9-year-old girl presents with a three-week history of lower abdominal discomfort. Upon physical examination a right adnexal mass is palpated, subsequently confirmed by radiologic evaluation. There is no evidence of abnormal secondary sexual characteristics. Surgical resection of the right adnexal structures reveals an intact cystic ovarian tumor with a smooth outer surface, measuring 12.0 cm in greatest dimension. Upon sectioning, close to 30% of the cut surface is cystic and 70% solid. The cystic, smooth-walled, tan areas are filled with serosanguinous fluid; the largest cyst measures 4.5 cm in greatest dimension. The solid component is tan and soft, without gross evidence of necrosis or hemorrhage. A grossly unremarkable fallopian tube is also present. No evidence of metastatic disease or ascites is noted.

A 28-year-old man presents with generalized adenopathy and weight loss. The patient is otherwise asymptomatic. Peripheral blood examination is normal. A firm mobile inguinal mass that developed over the last six months is removed. Gross examination reveals two fragments of soft tissue (30 and 20 grams), measuring up to 5.0 cm, with a lobulated tan cut surface. Immunophenotypic flow cytometry analysis reveals no clonal proliferation.

A 67-year-old man presents with complaints of hematuria and flank pain. A computerized tomography (CT) scan shows a 10.5 cm mass in the upper pole of the right kidney and retroperitoneum. The patient undergoes a right radical nephrectomy. Grossly, the tumor is yellow-tan and centered in the renal cortex. Tumor penetrates the renal capsule and extends into perinephric adipose tissue. Immunohistochemical evaluation demonstrates tumor cells expressing pan-cytokeratin (AE1/AE3), vimentin, and epithelial membrane antigen (EMA).

A 9-month-old boy presents with a painless abdominal mass. Imaging reveals a left renal mass and a left total nephrectomy is performed subsequently. Gross examination reveals a 6.5 cm lower pole tumor with a lobulated, bulging, rubbery tan cut surface.

A 60-year-old woman presents with abdominal pain. Physical examination reveals a large abdominal mass. A CT scan of the abdomen and pelvis shows a large cystic right ovarian mass extending from the pelvis to the abdominal cavity. She undergoes total abdominal hysterectomy with bilateral salpingo-oophorectomy, and bilateral pelvic and para-aortic lymph node dissections. Gross examination shows a markedly dilated unilocular ovarian cystic mass that measures 10.0 cm in greatest dimension, filled with thick brown, slightly mucinous fluid. The cyst contains a solid 6.0 x 3.5 cm area; scattered, variably thickened, coarsely nodular and broad-based papillary excrescences line the interior wall.

An 80-year-old woman presents with fatigue. Physical examination reveals splenomegaly, and laboratory studies show anemia and thrombocytopenia.

A 66-year-old man presents to his primary care physician with complaints of abdominal discomfort, fullness, nausea and vomiting, especially, after a meal. Physical examination reveals non-tender splenomegaly, which is 7.0 cm below the left costal margin. Complete blood count is normal. A CT scan reveals an enlarged spleen with multiple lesions interspersed within normal appearing parenchyma. A bone marrow biopsy, performed as part of the work-up to exclude a systemic lymphoma, was normal. Upper endoscopy reveals a gastric antral nodule, which on biopsy shows mild chronic gastritis and focal intestinal metaplasia. Staining for H. pylori is negative.

A 48-year-old woman presents with a deep, 7.0 cm mass in the vulvar region. The lesion is surgically excised revealing a gelatinous tan-purple mass with grossly indistinct boundaries.