Previous Pathology Case Challenges

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.

A 3-month-old infant is brought to their local pediatrician by parents concerned with a palpable abdominal mass. The infant's parents relate no history of fever or other significant perinatal abnormalities. A genetic history elicited by the pediatrician documents only a history of cystic fibrosis in the father's family. Following physical and radiologic examinations, the child undergoes a left radical nephrectomy. Gross examination of the kidney demonstrates a 7.9 cm circumscribed tan and firm mass present within the upper pole of the left kidney. Involvement of the renal vasculature is not identified.

A 60-year-old man with a 50 pack-year smoking history presents with complaints of persistent cough and pleuritic chest pain. Radiographs demonstrate a 2.5 cm solid, subpleural lesion with spiculated borders involving the left upper lobe. Following a diagnostic needle core biopsy, a lobectomy is performed. The external surface is remarkable for puckering of the pleura. Sectioning reveals a yellow-tan lesion beneath the area of puckering. The provided section is from the tumor. The patient additionally has metastatic disease in mediastinal lymph nodes and 5 months following surgery is discovered to have liver and adrenal metastases.

A 72-year-old woman with no significant history presents with a 4.0 cm eczematous, slowly spreading plaque in the vulvar area.

A 57-year-old woman presents with a breast mass. She has a history of invasive ductal carcinoma of the left breast 3 years ago, treated with partial mastectomy and postoperative radiation therapy.

A 60-year-old man presents to the emergency room with a possible appendicitis, with right lower quadrant acute abdominal pain and point tenderness that radiates to the scrotum. Physical exam reveals guarding and rebound tenderness. Peripheral blood examination is normal. Imaging reveals a lobulated hemorrhagic 7.0 cm mesenteric and omental mass with periappendicitis and engorged peripheral vessels; abdominal exploration, mass resection and appendectomy are performed. Gross examination reveals a 7.0 cm lobulated, tan, soft mass of the omentum, mesentery and mesoappendix, with a fleshy cut surface.

A 19-year-old woman presents with abdominal pain and a pelvic mass. Left salpingo-oophorectomy reveals a 1368.0 g, 20.0 x 12.0 x 10.5 cm ovary. Its external surface is smooth and pink without capsular disruption. Sectioning reveals a multiloculated cystic and solid mass. The cyst wall lining is tan-pink, smooth, and ranges from 0.1 to 0.3 cm in thickness. The solid areas are variegated clear, translucent, tan, and dark red with hemorrhage.

A 58-year-old man undergoes surveillance colonoscopy and this 2.8 cm pedunculated polyp is removed from his sigmoid colon. He has a long history of similar polyps, the first of which was removed when he was 12 years old when he presented with rectal bleeding.

An 80-year-old man presents with a firm mobile inguinal mass that developed rapidly over the last 6 weeks. The patient is otherwise asymptomatic. Chest X-ray is unremarkable. Peripheral blood examination is normal. Excisional biopsy is performed. Gross examination reveals a 3.5 cm well-circumscribed firm mass with fleshy cut surface. Tumor cells demonstrate cytokeratin 20 and synaptophysin reactivity and are negative for prostate specific antigen and TTF-1.

A 42-year-old woman presents with complaints of abdominal bloating. Bimanual exam reveals a palpable left abdomino-pelvic mass, and CT scan shows a 12.0 cm mass effacing the left ovary. Numerous septations with fluid levels are visualized. At surgery, a multi-lobulated cystic mass is resected with intraoperative rupture revealing jelly-like pinkish cyst contents. A few grossly necrotic areas are seen. No other gross lesions are noted, and on microscopic exam, the other ovary, both fallopian tubes, and uterus are unremarkable. Immunoevaluation reveals the tumor cells to express cytokeratin 7, CA 19.9, and CDX2; they are weakly and focally expressive of cytokeratin 20.

A 52-year-old woman presents with gross hematuria and a left flank mass. A CT scan of the abdomen shows a homogenous enhancing mass, 8.0 x 6.0 cm arising from the upper pole of the left kidney. Radical nephrectomy specimen shows an 8.5 x 6.0 x 3.0 cm well-circumscribed solid mass with a grey-beige cut surface and small areas of calcification and necrosis.

A 57-year-old Hispanic man had a long history of non-ischemic dilated cardiomyopathy. He grew up on a farm in El Salvador and immigrated to the United States as a young man where he has worked as a manual laborer all of his life. His course was complicated by arrhythmias, progressive intractable ventricular tachycardia and AV node block. Following numerous clinical interventions spanning several years, orthotopic heart transplantation was performed. Four months later, the patient developed severe cardiac failure. A cardiac biopsy was performed and a laboratory assay was obtained, both of which proved to be diagnostic for a disease process. In spite of aggressive therapy, his disease worsened and he died two weeks later. An autopsy was performed. The glass slide provided contains a representative sample of the transplanted heart.

A 9-year-old boy is found to have abdominal distention and an abdominal mass and undergoes a right lobectomy of the liver. A 12.5 cm heterogeneous hemorrhagic, soft solid and focally cystic mass is identified in the liver. The tumor appears fairly well circumscribed, and focally is associated with rupture of the capsular surface. The tumor is located 0.3 cm from the nearest surgical margin. The surrounding hepatic parenchyma appears congested.

A 63-year-old man presents to the emergency room with a ruptured spleen and an emergency splenectomy was done. He carries a diagnosis of a myeloproliferative neoplasm, for the past 2 years and has progressively become pancytopenic. His peripheral blood smear shows a leuko-erythroblastic picture.

A 65-year-old man presents with a painful left pelvic mass of four months duration. The pain is intermittent, is noted at rest and becomes worst at night. Radiographs reveal an 8.4 cm intramedullary lucent lesion of the left pelvic bone that contains irregular punctate opacities. The lesion extends through the cortex that demonstrates prominent adjacent periosteal reaction, and involves soft tissue. There is no history of previous radiation to this area. The lesion is resected and represented by the enclosed slide.