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Skin biopsy from the leg for bilateral lower extremity edema in an elderly female.
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#50- focal nodal involvement with hodgkin's?
#51-intravascular lymphoma?
 
for caffeinegirl's case:

non-classical Hodgkin lymphoma? Think I can see some popcorn-like cells in the 20X pic.

Am enjoying this thread too, although it is distressing to see how much less comfortable with diagnostic path I am after 5 months of FP fellowship.
 
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# 50..is it nodular LP- Hodgkin lymphoma?- Looks like popcorn cells with rosetting
 
Check out a high power of my case (#50). And compare it to the pattern at low power....should help you classify this. Anybody know what stains to order??

For Autopsy101's case (#51) I'm at intravascular lymphoma vs. carcinoma...would do a keratin and CD20 stain to start with...
Definitely an interesting and unexpected finding in what clinically probably looked like venous stasis!
 

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caffeinegirl said:
Check out a high power of my case (#50). And compare it to the pattern at low power....should help you classify this. Anybody know what stains to order??

For AutopsySweet's case (#51) I'm at intravascular lymphoma vs. carcinoma...would do a keratin and CD20 stain to start with...
Definitely an interesting and unexpected finding in what clinically probably looked like venous stasis!
Click to expand...

When I see big nucleoli, I don't usually think of lymphocyte predominant/popcorn cells, (although I could be totally wrong!) If it is classical Hodgkins, I don't see any sclerosis, so nodular sclerosis would be out. Lymphocyte depleted is also out. There seems to be a fair bit of plasma cells, so maybe it could be mixed cellularity (but I would think there would be some eos mixed in, and I don't see them). So I guess I'm at lymphocyte rich versus mixed cellularity. The EBV could maybe help sort that out.

I'd also worry about EBV-associated lymphadenopathy too.

I'd want a CD45, CD20,CD79a, Pax5, CD15, CD30 and ISH-EBER to figure out what is going on. :D
 
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Are we wrong about the Hodgkins?

Here is another case:

A older male with a tender skin nodule.
 

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Tiki said:
Are we wrong about the Hodgkins?
Click to expand...

You are correct about the Hodgkins! Just needed to load up the immuno's for you to see (CD15 and CD30). Called it mixed cellularity, given the architecture. Tricky case on low power though, since it focally involved the lymph node. You could easily blow by this node on low power as reactive with sinus histiocytes given the open sinuses....eeks!
 

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caffeinegirl said:
You are correct about the Hodgkins! Just needed to load up the immuno's for you to see (CD15 and CD30). Called it mixed cellularity, given the architecture. Tricky case on low power though, since it focally involved the lymph node. You could easily blow by this node on low power as reactive with sinus histiocytes given the open sinuses....eeks!
Click to expand...

Awesome, those are beautiful stains! Great case. I am always worried about missing lymphoproliferative disorders on lymph nodes, especially those that are removed looking for metastatic disease. I've missed cases of CLL and NLPHL in lymph node specimens because I turned on the tunnel vision looking for mets.
 
Tiki said:
Are we wrong about the Hodgkins?

Here is another case:

A 71 year old male with a tender skin nodule over his mastoid process.
Click to expand...

Interesting, awesome case. I would actually have to see the slide for this and look at these cells closely. There doesn't seem to be an epidermal component as far as I can make out. There is alot of acute inflammation and the cells are certainly very atypical (I think they have nuclear inclusions) but I don't see any mitoses. I cannot completely rule out an infectious reactive process with all that acute inflammation.
 
It looks like a metastatic carcinoma to me, but it is poorly differentiated, so who knows. The nuclear chromatin reminds me of nasopharyngeal carcinoma, but that is totally non-specific. I guess I would start with a keratin.
 
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Path or bust said:
Interesting, awesome case. I would actually have to see the slide for this and look at these cells closely. There doesn't seem to be an epidermal component as far as I can make out. There is alot of acute inflammation and the cells are certainly very atypical (I think they have nuclear inclusions) but I don't see any mitoses. I cannot completely rule out an infectious reactive process with all that acute inflammation.
Click to expand...

I'd like a pan-CK, S100, HMB-45. :)
 
I agree with Caffeine Girl, and I am suspicious for infectious causes. Any PAS stain? I thought I saw maybe some small, encapsulated fungus-like organisms in the cytoplasm. Thinking of cryptococcus or something.
 
Bone marrow biopsy and aspirate for worsening anemia and hx of renal transplant.
 

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I don't have a PAS but I do have this:
 

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Hey guys!

As a premed, it's very encouraging to see threads like this one where residents and attendings talk about interesting cases and don't just complain about poor compensation.

Based on other threads on studentdoctor I was beginning to think that the actual practice of medicine is secondary to worries about how much money you are making. You've restored my faith in the future :D :D

Keep up the good work.
 
So it was blasto and was confirmed with culture. There were some really nice broad based buds on the slide.

.
 
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kappa, lambda, CD30 - all negative

CD38 - this entity can rarely be positive for CD38 (although it wasn't done on this particular case)
 
What about histiocytic markers? Maybe a CD68 and CD1a? And I'll take a mast cell marker as well: either tryptase or CKit.
 
As a bit of an aside to this thread, how was pathology performed before IHC? By that I mean a very high percentage of cases are only signed out after immunos, and tough cases basically get the kitchen sink. For those of you doing diagnostic path, do you find this good or bad? I think I'd have found it very frustrating, especially if working in a smaller setting without the availability of immunos most of us probably get accustomed to in residency.
 
mlw03 said:
As a bit of an aside to this thread, how was pathology performed before IHC? By that I mean a very high percentage of cases are only signed out after immunos, and tough cases basically get the kitchen sink. For those of you doing diagnostic path, do you find this good or bad? I think I'd have found it very frustrating, especially if working in a smaller setting without the availability of immunos most of us probably get accustomed to in residency.
Click to expand...

it was very frustrating and morphology was much more strongly emphasized.
but you can see how we had so many more gastric epithelioid leiomyomas and such.
ihc was very rudimentary in the early 80's when i was a resident.it was pretty much keratin, s-100, vim and leukocyte common antigen (pre "CD" terminology days).
we used em lots more on the poorly differentiated/undifferentiated tumors.
 
Good thoughts everybody! Myeloid sarcoma/leukemia cutis as well as histiocytic lesions are definitely in the differential.

CD68 showed patchy dot-like cytoplasmic positivity in the cells of interest
View attachment CD68 20x.jpg

CD1a is negative (although it can rarely be positive in this entity)
MPO, CD34, CD117/ckit, mast cell tryptase - all negative

BTW - does anyone have a preference for leaving the images attached so you have to click them open vs. inserting them directly into the post?
 
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Euchromatin said:
Good thoughts everybody! Myeloid sarcoma/leukemia cutis as well as histiocytic lesions are definitely in the differential.

CD68 showed patchy dot-like cytoplasmic positivity in the cells of interest
View attachment 18238

CD1a is negative (although it can rarely be positive in this entity)
MPO, CD34, CD117/ckit, mast cell tryptase - all negative

BTW - does anyone have a preference for leaving the images attached so you have to click them open vs. inserting them directly into the post?
Click to expand...

Is this blastic plasmacytoid dendritic cell neoplasm? Great case! I sure have never seen one.
 
Autopsy101 said:
Bone marrow biopsy and aspirate for worsening anemia and hx of renal transplant.
Click to expand...


CMV?

I thought about parvo as well, but I don't see good erythrocytes with ground glass nuclei.
 
Autopsy101 said:
Bone marrow biopsy and aspirate for worsening anemia and hx of renal transplant.
Click to expand...

Yeah that's parvo I think. I had a really nice case of it once:

Flickr
108793743_0f3fef73d5_b.jpg
 
PCR was positive for parvovirus! Good job everyone :) All the other cases so far have been great. Case #75 - what about CD 4, CD 8, and CD 56? How about CD4+/CD56+ hematodermic neoplasm?
 
Autopsy101 said:
PCR was positive for parvovirus! Good job everyone :) All the other cases so far have been great. Case #75 - what about CD 4, CD 8, and CD 56? How about CD4+/CD56+ hematodermic neoplasm?
Click to expand...

i'm sure that is what it is. WHO updated the name from agranular cd4+/cd56+ hematodermic neoplasm to blastic plasmacytoid dendritic cell neoplasm in 2008
 
Autopsy101 said:
PCR was positive for parvovirus! Good job everyone :) All the other cases so far have been great. Case #75 - what about CD 4, CD 8, and CD 56? How about CD4+/CD56+ hematodermic neoplasm?
Click to expand...

Cool case! I've never seen a parvo, only in books!
 
WTG!!!

Blastic plasmacytoid dendritic cell neoplasm is correct. This case was positive for:
CD4
CD56
CD43
CD45 (LCA)
CD68 (in the dot-like pattern I showed before)

We also sent it out to get staining for CD123 and TdT (also positive)
 
Euchromatin said:
WTG!!!

Blastic plasmacytoid dendritic cell neoplasm is correct. This case was positive for:
CD4
CD56
CD43
CD45 (LCA)
CD68 (in the dot-like pattern I showed before)

We also sent it out to get staining for CD123 and TdT (also positive)
Click to expand...

thanks for sharing. the take home lesson for me, if i ever encounter one, is to think of these when encountering 1) old person
2) cutaneous
3) clearly hematolymphoid
4) negative for typical T's and B's
i first thought of plasma cells and mast cells but not this.
 
Here is another case:

Abdominal mass in a 13 year old girl.
 

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Tiki said:
Here is another case:

Abdominal mass in a 13 year old girl.
Click to expand...

has that "vascular/perivascular" "feel" to it. i don't think it is the "typical" small round etc like Ewings. I'll be back.
 
Looks classic for dsrct. Agree.
 
the only real case of dsrct i saw had very similar looking stroma, which the peds path attending told me is a very good H&E clue to the diagnosis. i hope we're wrong though - this diagnosis is a death sentence.
 
Yep, it's a DSRCT.

The immunos are really classic, I'll post them in a bit.
 
In order to keep this going, here is a nice easy/classic one for the more junior folks:
 

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