Case 1

SYLVIA L. ASA
University Health Network
Toronto, ON, Canada

Clinical Summary:

This 66 year old woman presented with a neck nodule. She had a history of a long-standing goiter. She was euthyroid; the goiter had been painless and non-tender. She had noted a sudden and rapid increase in size of her right neck in the preceding few weeks. On examination she had an assymetrical large goiter with a fixed 6 cm right nodule. She underwent thyroidectomy. The right lobe measured 6 x 5 x 5 cm and weighed 60 grams. It was multinodular with obvious infiltrating tumor. The left lobe weighed 6 grams and measured 4 x 3 x 1 cm with multiple small nodules measuring up to 5 mm in diameter.

The slide submitted is a representative section of the right thyroid.

Case 1 - Figure 1 - The thyroid contains an invasive solid tumor.

Case 1 - Figure 2 - The tumor is composed of a solid growth of neoplastic cells with focal inflammation, predominantly around vascular channels.

Case 1 - Figure 3 - The tumor cells are large and discohesive.

Case 1 - Figure 4 - The tumor cells have abundant cytoplasm with cytoplasmic inclusions; nuclear pleomorphism is prominent.

Case 1 - Figure 5 - Tumor cells have eccentric nuclei with prominent nucleoli and occasional binucleate cells are identified

Case 2

DAVID GRIGNON
Wayne State University
Detroit, MI

Clinical Summary:

A 70 year old man was found to have mass involving the right kidney during work up for right upper quadrant pain. There was no significant past history. A radical nephrectomy was performed. The gross description from the pathology report indicated that the kidney contained a "2.0 x 2.0 x 1.8 cm white-grey, fleshy tumor. It is located within the center of the specimen, and appears to involve part of the cortex and an entire pyramid."

Case 2 - Figure 1 - Mucinous tubular and spindle cell carcinoma. Low power photomicrograph illustrating the sharp circumscription of the tumor from the adjacent kidney.

Case 2 - Figure 2 - Mucinous tubular and spindle cell carcinoma. Intermediate power photomicrograph illustrating the tightly packed tubules with many having long open tubular profiles.

Case 2 - Figure 3 - Mucinous tubular and spindle cell carcinoma. Intermediate power photomicrograph highlighting the tubules some of which are collapsed without apparent lumens.

Case 2 - Figure 4 - Mucinous tubular and spindle cell carcinoma. High power photomicrograph illustrating the tubules. Note the prominent basal lamina around the tubules.

Case 3

CARMEN TORNOS
Memorial Sloan Kettering Cancer Center
New York, NY

Clinical Summary:

A 38 year old woman with a 3 cm palpable mass in the right axilla. The mass was excised. The photos are from this lesion.

Case 3 - Figure 1 - Metastatic low grade ovarian serous carcinoma to an axillary lymph node

Case 3 - Figure 2 - The tumor is predominantly papillary and it is associated with psammoma bodies.

Case 3 - Figure 3 - The lymph node has some benign-appearing cystic inclusions similar to "endosalpingiosis".

Case 3 - Figure 4 - Another area of the metastasis showing the papillary architecture and associated psammoma bodies.

Case 3 - Figure 5 - The metastasis has areas of invasion with desmoplastic stromal reaction, and invasion in the form of small papillae surrounded by a clear space or cleft.

Case 3 - Figure 6 - The tumor is papillary, it has uniform bland nuclei, and it is associated with psammomatous calcifications.

Case 3 - Figure 7 - Invasion in the form of small papillae surrounded by a clear space or cleft (so called "micropapillary type of invasion").

Case 3 - Figure 8 - High power showing rather uniform and bland nuclei, with finely distributed chromatin, inconspicuous nucleoli, and absence of mitotic activity.

Case 4

DAVID OWEN
Vancouver General Hospital
Vancouver, BC, Canada

Clinical Summary:

The patient is a 38 year old man who came to Vancouver from Hong Kong to seek treatment for a liver tumor which he had been told was unresectable. 18 years prior to this presentation he had an orchidectomy for a teratocarcinoma. At the present time his only symptom was recurrent febrile episodes. On examination he was found to have a mass in the liver. This measured 20cm in diameter and involved most of the left lobe and caudate lobe with compression of the portal vein and common bile duct No extra-hepatic lesions were identified.

Radical surgical excision was considered feasible. A mass weighing 1.5kg was excised. It was poorly circumscribed and the cut surface showed multiple necrotic and hemorrhagic foci interspersed with tan-grey tissue. The areas of background liver were non-cirrhotic.

Case 4 - Figure 1 - Low power view of lesion showing two different appearances: A densely cellular area and a sparsely cellular edematous area.

Case 4 - Figure 2 - Medium power view of the densely cellular area. At this power it is apparent that there is a spindle cell component and an inflammatory component.

Case 4 - Figure 3 - In this high power view the spindle cells are noted to be bland with little pleomorphism and no mitotic activity. The inflammatory cells consist of a mixture of lymphocytes, plasma cells and histiocytes.

Case 4 - Figure 4 - The edematous area of the lesion also shows an inflammatory component and a vascular component. Dense spindle cell aggregations are not seen.

Case 4 - Figure 5 - At this high power the bland nature of the spindle component is again demonstrated. The inflammatory cells are mixed and morphologically appear benign.

Note: Immunostains (not illustrated) show strong positivity for vimentin and KP1 with patchy positivity for smooth muscle actin. Negative results are obtained for CD 21, CD 23, CD 35 and ALK-1. The lymphocytes are mixed T and B cells. Cytogenetic analysis showed a clone 45-46,XY,add(3)(p13)+mar(5). ISH for EBV was negative.

Case 5

GREGORY N. FULLER
MD Anderson Cancer Center
Houston, TX

Clinical Summary:

A 56-year-old man presented with a history of a left parietal lobe glioblastoma that was surgically resected three months previously at a referring hospital, followed by radiation therapy. He reported increasing frequency of severe headaches and progressive motor and sensory changes on the right side of his body. A subsequent MRI scan revealed a new contrast-enhancing mass in the left parietal lobe at the site of his prior tumor, which was associated with extensive edema of the surrounding brain. The clinico-radiologic differential diagnosis included recurrent glioma, radiation necrosis, abscess, hemorrhage into the tumor bed, and venous infarction. Re-operation was performed for resection of the lesion to relieve the mass effect and provide tissue for a definitive diagnosis so that appropriate treatment could be instituted.

Case 5 - Figure 1 - Textiloma. Low power view of lesion reveals a heterogeneous mass with both hypocellular and hypercellular areas. (H&E, x20)

Case 5 - Figure 2 - Textiloma. At higher power, amorphous eosinophilic material is seen in association with an inflammatory cell infiltrate. (H&E, x100)

Case 5 - Figure 3 - Textiloma. In some fields, the eosinophilic material is seen to consist of smaller strands or cords. (H&E, x100)

Case 5 - Figure 4 - Textiloma. At high power, the inflammatory cell infiltrate is found to be dominated by eosinophils. Such a pronounced eosinophilic response is not seen in every case but when present is strongly suggestive of microfibrillar collagen (AviteneŽ) as the instigating hemostatic agent. (H&E, x400)

Case 5 - Figure 5 - Textiloma. Nodules of epithelioid cells (macrophages) may suggest granulomatous disease if the hemostatic agent is not identifiable. (H&E, x400)

Case 5 - Figure 6 - Textiloma. Foci of hemostat in an advanced stage of degeneration can resemble necrosis and, when surrounded by a hypercellular cuff of macrophages, might suggest necrosis with pseudopalisading, particularly in patients with a clinical history of glioblastoma. (H&E, x400)