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Head/Neck/Endocrine Pathology
Monday, February 28, 2011, 7:30 PM
CC 006 A/B
Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on each slide thumbnail image for an enlarged view
Diagnostic Delights in Head and Neck/Endocrine Pathology
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Moderator:
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MARY RICHARDSON
Medical University of South Carolina, Charleston, SC
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Disclosure:
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In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose. |
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Panelists:
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Diane P. Kowalski, Yale University School of Medicine, New Haven, CT
Peter M. Sadow, Massachusetts General Hospital, Boston, MA
Raja R. Seethala, University of Pittsburgh Medical center, Pittsburgh, PA
Bruce M. Wenig, Beth Israel Medical Center, New York, NY
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Clinical Histories and Still Images are displayed below.
Click on slide thumbnail images for an enlarged view.
If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137.
for Text and References
Submitted by: Diane P. Kowalski -
This is a 62-year-old woman with a history of significant life long developmental delay. She presented to her primary care physician complaining of a 2-month history of nasal congestion and posterior nasal pain. Family denied complaints of fever, chills, night sweats, weight loss or weakness. Cranial nerves were intact. She was tried on multiple treatments, including systemic steroids, antibiotics, decongestants and nasal steroids, without improvement of her symptoms. She was then referred to an ENT specialist. Nasal endoscopy revealed a submucosal polypoid mass in the nasopharynx. CT scan of the sinuses revealed a soft tissue density centered within the posterior ethmoid sinus, extending into the sphenoid sinus, eroding surrounding bone, with extension to the base of skull. Subsequent MRI revealed a 7 cm mass centered roughly in the sphenoid sinus region with involvement of the entire clivus. There was no evidence of intracranial extension. The tumor was felt to be unresectable.
Case 1 - Figure 1
MRI: Unresectable large sinonasal, skull base tumor, ptuitary fossa normal.
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Case 1 - Figure 2
Low power of cellular tumor with surrounding fibrous tissue and respiratory mucosa
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Case 1 - Figure 3
Medium power with uniform population of cells in nests with moderate eosinophilic cytoplasm
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Case 1 - Figure 4
High power with minimal cytologic atypia and pseudorosettes
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for Text and References
Submitted by: Peter M. Sadow -
From the surgeon's note (abridged): 65 year old tax accountant with a history of recent hypothyroidism. Exam in December 2009 for a right neck tenderness revealed a hard right thyroid nodule. Ultrasound showed a 3 cm right upper pole nodule. FNA came back positive for papillary carcinoma. She notes no further recent enlargement and denies related symptoms. ?On review of systems, the patient has no neck pain, dysphagia, choking sensation, change in voice or energy. No intolerance of heat or cold, palpitations, skin changes, or shortness of breath. Complete review is otherwise negative in detail. No family history of thyroid cancer or other endocrine tumors, but a brother with Graves disease. No history of head/neck irradiation. Her past medical history includes uncomplicated ovarian cystectomy. ?Her medications are levothyroxine 75 mcg daily and MVI. ? On examination, she is a well-appearing woman, in no distress, 5'3", 153#, 148/90, HR70, RR14. She has a normal affect and judgment and ability to communicate. Her eyes are anicteric. She has no lid lag or stare. Her oropharynx is clear. Her neck is supple. Her trachea is midline. Her carotid upstrokes are normal bilaterally. Her thyroid has a rock hard, 3cm right thyroid mass which is mobile, nontender. There is no cervical lymphadenopathy. Her chest is clear to auscultation and percussion. Her heart is regular rate and rhythm with no murmurs. Her extremities are without clubbing, cyanosis, edema or tremor. Her skin is warm and dry. The patient has a 3 cm papillary thyroid cancer which has a generally excellent prognosis. I detect no signs of metastasis or local invasion. I therefore recommended total thyroidectomy which would then be followed by radioiodine ablation for her best chance of cure. I reviewed the technique of surgery as well as the risks which are low but include life-threatening bleeding, infection, parathyroid damage, and voice damage. I reviewed my strategies for minimizing these and she would like to proceed this week. We will plan the surgery accordingly. I will also obtain a neck ultrasound to assess her lymph nodes prior to surgery.
Case 2 - Slide 1
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Case 2 - Figure 1
100X image showing a striking micropapillary pattern with fibrovascular cores and no colloid.
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Case 2 - Figure 2
400X image where the prominent apical snouts are seen as well as classical papillary carcnoma- type nuclear features.
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Case 2 - Figure 3
1000X image reveals similar features as the 400X image, including apically placed oval nuclei.
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Case 2- Figure 4
Immunohistochemistry displaying strong positivity for keratin 7 and keratin 19, as well as epithelial membrane antigen. TTF shows nuclear positivity.
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Case 2 - Figure 5
Cells are positive, in a membranous staining pattern, for beta catenin and E-cadherin. Nuclei are multifocally positive for p53 with a ki-67 proliferative index of 8%.
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Case 2 - Figure 6
40X image of a spindle cell proliferation adjacent to the papillary carcinoma.
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Case 2 - Figure 7
This 400X image is a zoom in .on the spindle cell component of the tumor showing tapered nuclei that are somewhat pleomorphic, focally hyperchromatic, and atypical.
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Case 2 - Figure 8
Immunohistochemistry performed on the spindle cell component shows the cells to have striking positivity for keratin 7 and keratin cocktail (AE1/AE3/CAM5.2), as well as scattered p53 nuclear staining with a marked elevation in the ki-67 proliferation index up to 30%, supporting the diagnosis of an undifferentiated carcinoma.
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for Text and References
Submitted by: Raja R. Seethala -
This is a 55 year old male with an 'indolent' right level II neck mass, found incidentally on clinical inspection. The patient has no known history of tobacco use. A prior fine-needle aspiration was performed and demonstrated a lymphocytic population. Flow cytometric analysis was reportedly limited due to low cell viability. The patient subsequently underwent excision of this neck mass.
Grossly, the excision contained a 3.0 x 2.0 x 0.6 cm tan- white ovoid mass with focal cystic change.
Case 3 - Slide 1
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Case 3 - Figure 1
Whole slide scan demonstrating a cystic mass (right) within lymphoid rich stroma
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Case 3 - Figure 2
The cystic lesion shows architectural complexity comprised of macro and microcysts with papillary invaginations
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Case 3 - Figure 3
The cystic spaces are line by a fairly monomorphic outer squamoid layer and an inner columnar layer.
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Case 3 - Figure 4
Mucocytes are noted within the innermost layer of some of the cysts
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Case 3 - Figure 9
A cytokeratin 5/6 is positive mainly in the outer more squamoid layers of the cystic spaces.
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Case 3 - Figure 10
A p63 immunostain similarly highlights mainly the squamoid outer layers of the cystic spaces.
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Case 3 - Figure 11
MAML2 breakapart FISH shows no evidence of a rearrangement
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Case 3 - Figure 12
A p16 immunostain is diffusely strongly positive
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Case 3 - Figure 13
In-situ hybridization for HPV DNA (pan- selective probe set) shows punctate positivity in tumor cells. Inset – the glandular and ciliated cells are also positive.
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for Text and References
Submitted by: Bruce M. Wenig -
22 year old female presented with asymmetric enlargement of the left lobe of the thyroid gland. No information available relative to a prior fine needle aspiration biopsy. A left lobectomy was performed. Intraoperative consultation diagnosis was "Folliuclar pattern lesion, defer to permanent section."
Gross description: Left thyroid lobe measuring 6.5 x 3.5 x 3.5cm showing multiple circumscribed but not grossly encapsulated lesions, including a dominant nodule measuring 3.5cm in greatest dimension with a tan-yellow appearance and central hemorrhagic appearing area.
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