Previous Pathology Case Challenges

A 42-year-old woman presents with right upper quadrant pain. Physical examination reveals no abnormalities. Her laboratory evaluation is remarkable for a 2-fold increase in alkaline phosphatase, but otherwise normal liver function tests and a normal complete blood count. Computed tomography (CT) scan shows multiple nodular lesions involving her entire liver. These lesions are hypoechoic on liver ultrasound. Given the imaging findings, serum tumor markers are evaluated including alpha-fetoprotein, carcinoembryonic antigen, CA19-9, CA125 and CA27-29, all of which are normal. She undergoes wedge biopsy of one of the liver nodules and subsequently undergoes orthotopic liver transplantation. The gross examination of the explanted liver shows the entire liver to be involved by multiple grey-white ill-defined nodules ranging from 0.5 cm – 10.0 cm and replacing about half of the liver parenchyma. The slide presented is comprised of a representative nodule from the explanted liver.

A 48-year-old woman presents with hypothyroidism treated with high dose Synthroid® for the past 28 months. Recently, she has developed marked dysphagia and dyspnea. She has a history of classical Hodgkin lymphoma 20 years ago. Physical exam reveals a firm to hard, slightly enlarged asymmetric thyroid gland. There is no lymphadenopathy. Laboratory findings include elevated serum TSH, elevated antithyroglobulin antibody titer of 1:4096, elevated antithyroid peroxidase antibody titer of 1:2048, and mild normocytic, normochromic anemia (Hct-34%). The thyroid is resected revealing a diffusely firm, pale gray, slightly enlarged lobulated segment of tissue with a well-delineated capsule and without extension into surrounding soft tissue. No definitive normal thyroid tissue is visible grossly.

A 50-year-old woman presents with a sudden onset of right flank pain following a 2–3 day history of low-grade fevers. She recalls having urinary tract infections in the distant past. Currently, she does not respond to antibiotic therapy. A computerized tomography (CT scan) shows an irregularly shaped right kidney with dilatation of the pelvis but no evidence of urinary tract calculi. She undergoes a right simple nephrectomy. Gross examination demonstrates a deformed 8.7 x 7.1 x 4.0 cm kidney with a coarsely granular cortical surface. Serial sections reveal blunted renal calyces with firm gray-white areas, interspersed tan-pink parenchyma, a dilated renal pelvis and proximal ureteral thickening.

A 48-year-old man complains of a growing tender right neck mass. The patient has no other significant clinical symptoms. At operation, the mass proves to be multiple lymph nodes, the largest of which measures 7.0 cm. Histologic sections show numerous large cells infiltrating lymph nodes. These cells are strongly positive for CD30, variably positive for CD15, dimly positive for PAX5, and negative for CD20 and CD45.

A 62-year-old woman presents with weight loss, shortness of breath, and chest pain. Chest x-ray shows a pleural effusion. Chest computed tomography (CT scan) shows multiple pleural tumor nodules on the right side. An extrapleural pneumonectomy is performed. Gross examination reveals a diffuse pleural rind on the right lung along with two pleural masses measuring 7.0 x 5.5 x 5.0 cm and 5.5 x 4.0 x 4.0 cm, respectively. Immunoevaluation reveals the tumor cells to express cytokeratin 5/6, calretinin, Wilms tumor 1 protein (WT-1), and negative staining with thyroid transcription factor 1 (TTF-1) and BerEP4.

A 53-year-old man with clinical history of hypertension and hypercholesterolemia is admitted to the emergency room due to a possible stroke. A transthoracic echocardiogram is unremarkable. On further evaluation, a transesophageal echocardiogram reveals an oval and pedunculated mass, measuring 2.0 cm, adherent to the left atrial wall. The mass is mobile and distensible, protruding to the left atrial appendage during atrial systole. Due to its embolic potential, the mass is removed. The resected mass is soft, polypoid, and pedunculated, with a gelatinous cut surface and focal dark red areas on the periphery.

A 72-year-old man with left leg below knee amputation presents with a large exophytic and fungating mass involving the amputation stump.

A 34-year-old G4 P3-0-0-3 presents at 27 weeks’ gestation with complaints of decreased fetal movement for 3 days, fever of 101.3°F, chills, and body aches. White blood count is 19,900/mm3 with increased neutrophils and band forms. Ultrasound examination shows fetal demise. The fetus is delivered with foul-smelling amniotic fluid, and the placenta shows a yellow-green opaque fetal surface with features suggestive of necrotizing funisitis.

A 53-year-old woman presents with a 4-week history of intermittent right lower quadrant pain. Upon pelvic examination, a firm right adnexal mass is palpated. Subsequent radiologic evaluation confirms the presence of a solid ovarian mass. Surgical resection reveals a firm mass with a white-yellow bosselated outer surface measuring 8.0 cm in greatest dimension, located on the upper pole of an otherwise grossly unremarkable ovary. Upon sectioning, the ovarian mass has firm, white-yellow and glistening cut surfaces, without gross evidence of necrosis, hemorrhage, calcification, and/or cystic change.

A 26-month-old boy is brought to the local pediatrician by parents concerned with a protuberant mass present on the medial aspect of the right thigh. The infant's parents relate no history of fever or other significant perinatal abnormalities. A genetic history reveals several paternal relatives with an unspecified genetic condition. Physical examination documents a 4.5 cm thigh mass. No cutaneous involvement is noted. Magnetic resonance imaging of the extremity reveals a 4.2 x 3.0 x 3.0 cm soft tissue mass. The child undergoes biopsy of the mass and subsequent excision. Gross examination reveals a soft and fleshy tan-gray tumor with focal hemorrhage and necrosis. Immunohistochemistry demonstrates tumor cells staining for vimentin, cytokeratin, and focally for S100 protein, but staining for INI-1 is negative. Immunohistochemical stains for CD34, CD45 (LCA), desmin, myogenin, and MyoD1 are negative.

A 40-year-old woman presents with left neck swelling, stridor, and dysphagia. Physical examination reveals a left neck mass. The patient is euthyroid and thyroid function tests are within normal limits. She has no family history of thyroid disorders and no history of head and neck radiation. Computed tomography shows tracheal compression and numerous thyroid nodules in the left thyroid lobe; the right thyroid lobe is unremarkable. A fine needle aspiration (FNA) of the left thyroid lobe is interpreted as “follicular lesion of undetermined significance.” Left thyroid lobectomy is performed. A 60 g thyroid lobectomy shows numerous vague glistening nodules, 1.1 to 4.5 cm, with semitranslucent content, involving the entire lobe. Rare incomplete fibrous strands partially surround some of the nodules. Only a thin rim of unremarkable thyroid tissue is identified at the periphery of the lobe.

A 46-year-old woman presents with progressive hirsutism. Laboratory studies show an elevated serum testosterone level. Pelvic ultrasound demonstrates a slightly enlarged left ovary. Total hysterectomy, bilateral salpingo-oophorectomy, and omental and peritoneal biopsies are performed. Gross examination of the left ovary reveals a 3.8 x 3.5 x 3.4 cm well circumscribed tan-yellow nodule within the ovarian parenchyma. The external surface of the ovary is smooth and tan without disruption.

A 24-year-old woman presents for a routine prenatal visit at five months’ gestation. During her exam a palpable 1.0 cm mass is noted in her right breast. A follow-up ultrasound shows a circumscribed, 1.6 cm hypoechoic nodule. An ultrasound-guided core biopsy is performed. Three months after an uneventful delivery, a 2.2 cm circumscribed, unencapsulated nodule with a markedly myxoid, light yellow-tan cut surface is excised.

A 23-year-old G1P0 woman delivers a female neonate at 32 weeks’ gestation. The neonate has Apgar scores of 5 and 7 at one and five minutes, respectively, and is admitted to the neonatal intensive care unit due to pallor and respiratory distress. She is small for gestational age and has thrombocytopenia (platelets 80,000/mcl), but no anomalies are identified. The placenta weighs 1300 g and shows a large intraparenchymal mass measuring 10.0 cm in greatest dimension. The mass is dark red-purple on the cut surface and appears circumscribed but not encapsulated. No other lesions are identified grossly. A representative section of the placental lesion is provided.

A 20-year-old man presents with an enlarging right testicular mass. Serum tumor marker levels are obtained prior to the radical orchiectomy with the following results: AFP, 968 ng/mL; Beta-hCG, 7 IU/L; and LDH, 236 IU/L. Gross examination of the testis reveals a single 3.0 cm somewhat circumscribed, soft, white to pale yellow mass with focal cystic degeneration, hemorrhage, and small areas of necrosis.

A 52-year-old woman was diagnosed with invasive rectal adenocarcinoma on a recent colonoscopy. At laporatomy, an incidental firm 8.0 x 6.0 x 4.0 cm rounded mass is identified in the mesentery. Sections of the mass are submitted for flow cytometric, microscopic, and immunohistochemical analysis. Immunohistochemical studies reveal scattered larger cells are positive for CD45, CD20, CD79a, bcl-6, and EMA (weak). They are negative for CD30, CD15, and EBV-associated latent membrane protein (LMP). CD21 reveals scattered follicular dendritic meshworks. Other immunohistochemical and flow cytometric studies reveal a T-cell dominant profile, a small subset of which are positive for CD57.

A 33-year-old woman presents with cough and chest tightness for the past month. She was diagnosed with myasthenia gravis 5 months ago, but otherwise has no significant medical history. Chest x-ray demonstrates a large mass in the anterior mediastinum, which on CT is noted to measure 10.0 x 7.5 x 6.0 cm. CT-guided percutaneous biopsy is performed.

A 59-year-old man presents with an incidental renal mass on CT scan. An 880 g radical nephrectomy specimen shows a 10.0 x 9.0 x 8.0 cm well-circumscribed mass at the upper pole of the kidney. The mass is diffusely hemorrhagic with multiple foci of necrosis. A second 5.0 x 5.0 x 3.0 cm mass with a similar appearance is adjacent to the larger mass. The tumors are confined to the kidney and do not invade peri-nephric adipose tissue, renal sinus, or renal vein. The adjacent kidney parenchyma is unremarkable.

A 49-year-old woman presents with abdominal pain. Workup reveals a left adrenal mass and surgical intervention is undertaken. The resection specimen demonstrates a 15.0 cm mass replacing the adrenal gland, with local infiltration into soft tissue, kidney, and spleen. Several large-caliber veins grossly contain tumor thrombi. Cut section shows extensive necrosis and hemorrhage.

A 32-year-old man presents with a thigh mass of 6 months' duration. Physical exam reveals a large subcutaneous and deep firm, non-tender mass on his right lateral thigh. The lesion does not extend through the skin. CT-scan demonstrates a 6.3 cm solid mass in deep soft tissue of the right lateral thigh that focally extends into skeletal muscle but does not involve bone. The lesion is excised. Gross exam of the excision reveals a 6.2 x 5.7 x 5.1 cm well circumscribed, firm, tan homogeneous mass without hemorrhage or necrosis.