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Previous Cases of the Month

  • Third Trimester Placenta

    A 22-year-old G2P1 woman is admitted in labor via the emergency room (ER) to a local hospital. She informs the admitting physician that based on prior ultrasound evaluations her fetus exhibits findings consistent with intrauterine growth restriction and that she regularly visits the hospital’s obstetrical service, where she is being followed by a staff gynecologist. At the time of admission, she denies fever, cough, or skin rashes. Evaluation of her chart reveals that she is 37 weeks pregnant (by dates). Also noted are several pre-natal laboratory results, including the following: HBsAg-negative, RPR non-reactive, Rubella-immune, HIV non-reactive, GC-negative, and Chlamydia-negative. Due to fetal distress, she delivers via Cesarean-section later that day; the newborn male is small for gestational age. The placenta is submitted to the pathology department for evaluation.

  • Skin and soft tissue of right forearm

    A 45-year-old healthy construction worker sustains a superficial laceration to his arm at his worksite. He does not receive any immediate medical attention for the cut. Several weeks later he develops generalized erythema and discoloration of the skin of the upper extremity in the region of previous trauma. He finally requests medical attention due to pain and stiffness that prevents him from working. He requires an extensive surgical debridement of the skin and subcutaneous tissue for control of disease. At the time of surgery, material from the soft tissue wound is submitted for culture.

  • Soft tissue

    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.

  • Brain

    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.

  • Liver

    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.

  • Thymus

    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.

  • Lung

    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.

  • Colon

    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.

  • Liver

    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.

  • Mesentery

    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.

  • Posterior neck

    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.

  • Heart

    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.

  • Ovary

    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.

  • Liver

    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.

  • Peritoneum

    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.

  • Liver

    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.

  • Mediastinum

    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.

  • Liver

    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.

  • Breast

    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.

  • Vagina

    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.

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