Interesting/educational cases

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Pollux

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Well, I thought that this board could probably use something other than the recurrent discussions on job market/healthcare reform/decrease in reimbursement/etc, so I'm going to start posting some interesting or educational surgical pathology cases that I came across recently.

Feel free to post your diagnosis or ask for stains, and of course you're more than welcome to post interesting/educational cases that come across your desk too.

Also, please let me know if I should post the photos as attachments (like case 1) or full images (like case 2). The full images will just load automatically without requiring people to manually click on each image, but might take longer to load once I start posting more cases.
 
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1. 56 year old male with a bladder polyp.

Image_235.tif.jpg Image_246.tif.jpg image.jpg image.jpg
 
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2. 41 year old female with bilateral pulmonary infiltrates.

Histologically shows multiple nodular lesions in the pulmonary parenchyma. The photomicrographs are from 3 representative nodules.

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Pollux said:
2. 41 year old female with bilateral pulmonary infiltrates.

Histologically shows multiple nodular lesions in the pulmonary parenchyma. The photomicrographs are from 3 representative nodules.

View attachment 181024 View attachment 181025 View attachment 181026 View attachment 181027 View attachment 181028
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1. Polypoid cystitis with atypical stromal cells.
If panCK is positive in the stromal cells, then invasive carcinoma with perineural invasion

2. LAM if positive for melanoma markers
 
greencreek said:
1. Polypoid cystitis with atypical stromal cells.
If panCK is positive in the stromal cells, then invasive carcinoma with perineural invasion

2. LAM if positive for melanoma markers
Click to expand...

1. PanCK is negative, but this is NOT just another case of atypical stromal cells though.

2. The foci of LAM are positive for SMA and HMB45. However, it's only part of the entire process. The non-spindle cell foci (as seen in images 1, 2, 4, and 5) also form nodular lesions scattered throughout the entire specimen.
 
Obviously I have no idea re: diagnoses but wanted to say great idea!
 
I need S100 for the first one. Ganglion cells?

The second one I am in between Meningioma and Organizing pneumonia. Need EMA or PR/
 
alaska82 said:
I need S100 for the first one. Ganglion cells?

The second one I am in between Meningioma and Organizing pneumonia. Need EMA or PR/
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1. S-100 would be negative in those cells.

2. EMA would be positive and PR would be negative. It is not organizing pneumonia either.
 
1. Cystitis secondary to polyoma virus. Those look like decoy cells. Maybe yaah can confirm, he's the GU person.
 
post radiation atypia for the first
Well differentiated adenocarcinoma for the second, like fetal type?
 
I would perform a B-HCG on the bladder polyp.

I can't make out the cells in the PLAM case that aren't the PLAM cells. How would a CD68 and S100 look?
 
Some good thoughts/differentials raised. Here are the answers to the first two cases:

1. Extramedullary hematopoiesis involving the bladder. The large cells are dysplastic megakaryocytes (CD61+). There are also scattered erythroid and myeloid elements in the background. The patient did not have a history of myeloproliferative neoplasm, but was found to have pancytopenia a few months later. A BM Bx showed myelofibrosis.

2. Pulmonary lymphangioleiomyomatosis and micronodular pneumocyte hyperplasia. When you have these two findings in the same slide, it's very suggestive for tuberous sclerosis complex. This patient indeed had tuberous sclerosis, and had a history of renal angiomyolipoma as well.
http://www.ncbi.nlm.nih.gov/pubmed/9537475
http://www.ncbi.nlm.nih.gov/pubmed/11406664

Hope that was somewhat fun/educational.
 
3. 20 year old male with a renal mass.

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I look forward to it. Nice cases.

Are these cases you have at your institution?
 
4. 48 year old female with hilar lymphadenopathy. Lymph nodes showed non-necrotizing granulomas and the following findings. A GMS stain is positive in these brown objects, which are not found within the granulomas.

Image_204.tif.jpg Image_203.tif.jpg
 
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5. 35 year old with a soft tissue mass in the thigh. Not a terribly challenging case, but the spectrum of morphology is very nicely illustrated.

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4. Hamazaki-Wesenberg bodies in sarcoidosis indeed!

5. Synovial sarcoma is in the differential for sure. The diagnostic feature is in the third picture.
 
6. 33 year old female with an intramuscular soft tissue mass in the arm. It's one of my favorite tumors because of its distinctive morphology.

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pathdoubled said:
How about Muc4 stain?
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It would be negative. No, this is not a low-grade fibromyxoid sarcoma.

The answer to #5 is indeed MPNST with tactoid (Wagner-Meissner corpuscles), glandular, and cartilaginous differentiation. On lower power, there's alternating hypercellular and hypocellular zones, creating a marble-like pattern. There is also accentuated perivascular cellularity, which is typical of this tumor. The feature shown in the third picture is called Wagner-Meissner corpuscles, suggesting tactoid differentiation, and is one of the diagnostic features of MPNST (although they can rarely be seen in other nerve sheath tumors). I would not call it a malignant Triton tumor for lack of rhabdomyoblastic differentiation.
 
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Looks like an intramuscular myxoma.
 
pollux, are you not doing this case discussion anymore? It was good to have it in the forum.
 
alaska82 said:
pollux, are you not doing this case discussion anymore? It was good to have it in the forum.
Click to expand...

Thanks for the encouragement. Just got done with the board exam here. I might post a few more cases this week.
 
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