Previous Cases of the Month

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Parotid Gland
Updated: Jan 08, 2018

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.

Updated: Dec 21, 2017

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.

Right Ovary
Updated: Dec 04, 2017

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.

Inguinal Lymph Node
Updated: Nov 16, 2017

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.

Updated: Nov 03, 2017

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).

Updated: Oct 25, 2017

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.

Right Ovary
Updated: Oct 16, 2017

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.

Updated: Sep 25, 2017

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

Updated: Sep 11, 2017

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.

Updated: Aug 22, 2017

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.

Updated: Aug 08, 2017

A 56-year-old woman presents with abnormal uterine bleeding. An endometrial biopsy is performed and the diagnosis leads to a decision to perform a hysterectomy.

A 48-year-old woman presents with a 12.5 cm intrathoracic, mediastinal, well-circumscribed mass that is adherent to the left upper lobe of the lung and near the 6th intercostal foramen. Radiologic heterogeneity is noted on chest CT with contrast.

Right Testicle
Updated: Jul 14, 2017

A 42-year-old man presents with a right testicular mass. Laboratory studies reveal normal serum AFP and HCG. Orchiectomy demonstrates a 5.0 cm homogeneous white-gray mass confined to the testicle, with minimal hemorrhage and necrosis.

Updated: Jun 23, 2017

A 21-year-old male presents with intermittent rectal bleeding. A Hemoccult® test is positive. Colonoscopy demonstrates over 100 polyps throughout the colon. Further questioning reveals that both his father and grandfather died at an early age from colon cancer. Mutational testing for the APC gene is positive and a restorative proctocolectomy is performed.

Updated: Jun 08, 2017

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.

Thyroid Gland
Updated: May 22, 2017

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.

Updated: May 01, 2017

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.

Right Neck
Updated: Apr 24, 2017

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.

Right Lung and Pleura
Updated: Apr 11, 2017

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.

Left Atrium, Heart
Updated: Mar 21, 2017

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.

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