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Presacral myelolipoma vs extramedullary hematopoesis

mikesheree

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Hi Path forum!

I biopsied a presacral mass last week and path came back as "myelolipoma vs EMH". Is it impossible to differentiate between the 2 on path? Thanks!

On a tiny bx I don’t think it would be possible. However, radiographic characteristics are different. Eur. J. Radiol,
Aug, 2017. Also, Stanford Medicine’s surgical pathology criterion on line points out some differences but these may not be readily apparent on small bx. Myelolipomas often have a lymphoid infiltrate. EMH typically does not.
 

Med Director New England

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These two are tough to differentiate histologically on small biopsy. Both are benign. More important to exclude liposarcoma in fat containing lesions in this location, which it sounds like you guys have done.

A case like this is a great opportunity to talk to your local pathologist, get to know him/her. Dialogue like this is really good between path and radiology.
 
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Dave1980

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However, radiographic characteristics are different. Eur. J. Radiol, Aug, 2017
Interesting you bring up that article. 1 of the 4 highlights is that " They have similar imaging features, often indistinguishable". Probably can't get an answer unless we do a tagged RBC or PET/CT and since they are both benign it isn't worth the time, money, radiation.
 

mikesheree

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Not sure if this info is relevant but I took 4 18 gauge really nice solid core biopsies. They were a bright red. I was hoping for a definitive diagnosis.

Both are benign so that's good but for my case files a definitive diagnosis would have been nice!

Not sure if this info is relevant but I took 4 18 gauge really nice solid core biopsies. They were a bright red. I was hoping for a definitive diagnosis.

Both are benign so that's good but for my case files a definitive diagnosis would have been nice!

In my opinion, there is absolutely nothing wrong with forming a definitive DX based on the INTEGRATION of all other data such as clinical presentation, radiology, labs, etc.
There ARE cases where the histology ALONE just is not pathognomonic.
 
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Dave1980

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In my opinion, there is absolutely nothing wrong with forming a definitive DX based on the INTEGRATION of all other data such as clinical presentation, radiology, labs, etc.
There ARE cases where the histology ALONE just is not pathognomonic.

Unfortunately there is nothing by CT, pathology (apparently), or the clinical presentation that can actually tell me which it is. It's a little frustrating because it seems like our pathologists don't actually commit to a diagnosis as often as the other 3 places I've worked.
 

mikesheree

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Unfortunately there is nothing by CT, pathology (apparently), or the clinical presentation that can actually tell me which it is. It's a little frustrating because it seems like our pathologists don't actually commit to a diagnosis as often as the other 3 places I've worked.

In this case, i am not surprised. Might be worthwhile to just inquire as to the presence of a significant lymphoid infiltrate.
 
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cmz

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Hi Path forum!

I biopsied a presacral mass last week and path came back as "myelolipoma vs EMH". Is it impossible to differentiate between the 2 on path? Thanks!

As long as pathology didn't miss a sarcoma or other malignant process, who cares? It's benign. If there is a clinical concern for the latter, maybe go back and get more tissue so they can make a definitive diagnosis. You should ask yourself if it makes sense for this lesion to be a myelolipoma (e.g. is there demonstration of a mass with fatty attenuation). Clinically, does it make more sense for the lesion to represent EMH? By that I mean, does the patient have a history of a chronic myeloproliferative disorder? Is there splenomegaly (maybe you can glean something from a CT since you're in the sacral area)?

Just to echo what Mike said, there is nothing wrong with the diagnosis given. You're best served with an appropriate radiologic read and delving into the clinical history.
 
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cmz

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Unfortunately there is nothing by CT, pathology (apparently), or the clinical presentation that can actually tell me which it is. It's a little frustrating because it seems like our pathologists don't actually commit to a diagnosis as often as the other 3 places I've worked.

I think you're likely questioning this benign diagnosis because prior reads have been unsatisfactory as the "pathologists don't actually commit to a diagnosis." You should have a chat with your pathologists.

Sometimes I joke within my group that certain cases require us to change our name to our favorite brand of cigarettes from the 1970s:

08c647e5a58f95003934d93e1503d93b.png
(that's me face down)

We can hedge the hell out of anything. When it comes to receiving a proper clinical history, we often feel we're being given the old "mushroom treatment" (fed $hit and kept in the dark).
 
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Med Director New England

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To echo the ^^ comments - talk to your pathologist about this case and any time you need to on future cases.

interventional radiologists really should know their sister path Dept very well. Cases like this come up all the time, the patients that you have in common will benefit from this.

I think equivocating between these two entities is not hedging at all, they often are indistinguishable on biopsy.
 
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HeyDalaron

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The field of pathology would benefit from dispelling the notion that we are the de facto gold standard for all things diagnostic.

We are but one piece of a larger puzzle. An important piece, but in the end just that.
 
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Pollux

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Hi Path forum!

I biopsied a presacral mass last week and path came back as "myelolipoma vs EMH". Is it impossible to differentiate between the 2 on path? Thanks!

Any CBC abnormalities or splenomegaly that would suggest a myeloproliferative neoplasm? Perhaps worth testing the patient's blood for JAK2 and MPL mutations and bcr-abl (unless you want to send the patient for a BM Bx)?

If any of the above is positive, then you're most likely dealing with EMH secondary to MPN. If all negative, then we are back to square one.
 

Dave1980

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Thanks for all the input. It's a complicated story. Here is the whole story...this thing was present but much smaller 10 years ago and composed of soft tissue and fat. At that time the H/H was normal. Over the next 8 years is almost doubled in size, H/H stayed normal, and it stayed soft tissue and fat. Then over the last 2 years the patient became anemic, the mass didn't grow at all but it became more solid appearing. That's when I biopsied it.

I kind of think it is extramedullary hematopoesis since it got more solid as the H/H dropped but it was also present 10 years ago when the patient was not anemic.
 
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