Case Collection2

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Case Collection-2

• Shashidhar.

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Thyroid Nodule

• Fine-needle aspiration biopsy of a thyroid nodule
  in a 52 years-old man. The nodule is located in
  the lower pole of right thyroid lobe, it measures
  about 2.5 cm in its greatest diameter and is
  easily palpable the patient is euthyroid and
  apparently in good health.

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Discussion

• Medullary carcinoma of thyroid (Shashi)
• C cells calcitonin secretion.
• Background shows amyloid.
• Highly cellular aspirate, uniform nuclei.
• Azurophilic granules in cytoplasm.
• Later age (5-7th decade).

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Discussion by Author

• This report illustrates a case of intrathyroid
  parathyroid carcinoma that masqueraded as a
  thyroid primary tumor both cytologically and
  clinically. The patient was first seen by an
  orthopedic doctor for evaluation of a back pain
  of increasing intensity. X-rays studies of the
  vertebral column and a laboratory blood test
  work-up followed. On physical examination a
  thyroid nodule was also palpated and the patient
  was seen by an endocrinologist. Ultrasound
  evaluation documented a solid, hypo-echoic nodule
  in the lower third of the left lobe of thyroid
  gland which was readily examined by FNA biopsy.

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• On microscopic evaluation of the aspirate our
  first impression was that of a medullary thyroid
  carcinoma (MTC) but the following cytologic
  features seemed not to fit with the diagnosis
  uniform cell size and lack of significant
  cellular pleomorphism complexity of cellular
  arrangement with frequent three-dimensional tight
  clusters and tendency to cell aggregation
  abundant monomorphic naked nuclei concomitant
  presence of both oncocytoid and clear cells lack
  of spindled or triangular cells. Moreover, the
  tumor was located in the lower thyroid pole,
  which is unusual for MTC.

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• In fact, cytologic features suggested a
  parathyroid lesion as an alternative diagnosis.
  Laboratory data which were made available soon
  after FNA biopsy sampling showed a calcemia of
  16.1 mg/dL, (n.v. 8.4-10.5), a phosphoremia of
  2.27 mg/dL (n.v. 2.5-4.5) and signs of slight
  renal insufficiency. These findings were
  consistent with a condition of hyperparathyroidism
  and strongly supported the above contention. Our
  FNA cytologic diagnosis was parathyroid tumor,
  uncertain if benign or malignant. Preoperative
  values of serum PTH were 2002 pg/ml (normal value
  8.0-76.0). The patient underwent right
  hemithyroidectomy with isthmus resection.

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• Histology of surgical specimen demonstrated a
  well circumscribed and encapsulated intrathyroid
  nodule Foto_6 microscopically, the architecture
  of tumor growth was either solid structureless,
  or multinodular, or trabecular with thick fibrous
  bands incompletely dividing the tumor. The tumor
  consisted of a population of medium sized
  polygonal oxyphilic and transitional oxyphylic
  parathyroid cells Foto_7 with occasional mitotic
  figures. Immunostaining for PTH was positive
  Foto_8. There were occasional necrotic areas.
  Foci of capsular disruption and pericapsular
  invasion into thyroid parenchyma in addition to
  intravascular tumor growth Foto_9 and minimal
  foci of extrathyroid invasion were also seen.
  These latter findings demonstrated the malignant
  nature of the tumor.

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• It is well known in the Literature that the
  distinction of parathyroid from thyroid cells in
  FNA samples can be challenging, and incorrect
  identification of parathyroid as thyroid lesions
  has been reported in a significant proportion of
  cases in the largest published series 1 2 3 4 5
  6. Potential trap is due to the finding in
  parathyroid lesions of aggregation patterns and
  cellular features, including intranuclear holes
  (cytoplasmic inclusions) 7, which overlap with
  those seen in thyroid follicular lesions 2 5 6 or
  Hurthle cell neoplasms 5 6, or papillary
  carcinoma 6 7. If the tumor exhibits a clear cell
  cytology it can be confused with a primary clear
  cell carcinoma of the thyroid. Naked nuclei can
  be misinterpreted as lymphocytes and suggest the
  diagnosis of lymphocytic thyroiditis 8. Finally,
  as in the present case, plasmacytoid or
  oncocytoid cellular morphology and intranuclear
  holes can simulate the FNA cytological picture of
  medullary thyroid carcinoma 6 9.

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Well circumscribed and encapsulated intrathyroid
nodule
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medium sized polygonal oxyphilic and transitional
oxyphylic parathyroid cells.
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Immunohistochemical expression for parathyroid
hormone.
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Intravascular spread.
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Case General Path,

• 18 years old patient with polyadenopathies.
  Clinical suspicion of tuberculosis because of
  positive familial epidemiology.

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Lateral cervical lymph node in 75 years old male.

• Antonio Félix Conde Martín
• Servicio de Anatomía PatológicaHospital Can
  MissesC/ Corona s/n Ibiza07800 Baleares
• Spain

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Clinical details

• Male 75 years old with multiple bilateral
  cervical lymphadenopathies. A fine needle
  aspiration cytology is performed.

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Discussion

• MALIGNANT NON HODGKIN HIGH GRADE B CELL LYMPHOMA
  (CENTROBLASTIC).
• IHQ la población tumoral es de estirpe B-CD20,
  CD79a, prolifera con MIB1 en un 80, siendo p53
  positivo en un 10 de las células. CD10-, BCL-6,
  BCL-2 irregular. Quedan escasas células T
  preservadas y son abundantes los histiocitos
  CD68.

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Discussion

• The smears are composed of a monomorphous
  population of cells with large nuclei with
  several nucleoli near the nuclear membrane and
  scant cytoplasm (centroblasts). According with
  these features the diagnosis of high grade non
  Hodgkin lymphoma was suggested. A lymph node
  biopsy is performed.
• Histological sections show lymph node
  architectural effacement by medium to large size
  lymphoid cells with clear nuclei with prominent
  nucleoli and scant cytoplasm. The intestitium
  shares different degrees of fibrosis.

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IHC-Immuno histo-chem

• the tumoral population is B-cell lineage CD20,
  CD79a. Proliferation index 80 (MIB1). p53
  positive in 10 of cells. CD10-, BCL-6. BCL-2
  irregular positivity. Seldom T cells preserved.
  Abundant CD68 histiocytes.

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Thank You!

• First of all thank you very much to all those who
  have participated with your commentaries. It is
  very stimulating for us to know that every week
  we count on so many and so great pathologists at
  this forum.

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Man with acute abdomen.

• E-medicine
• Image case

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History

• This 42-year-old man presents to the emergency
  department after approximately 30 hours of
  abdominal pain. The patient's pain was initially
  mild, constant, and periumbilical, lasting nearly
  10 hours before resolving. After he ate
  breakfast, the pain returned to the right lower
  quadrant and gradually progressed over the next
  20 hours.

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History

• The patient denies any fever, nausea, vomiting,
  diarrhea, constipation, bloody stools, weight
  loss, testicular pain, or anorexia. Physical
  examination reveals an afebrile, well-appearing
  man with localized voluntary guarding and rebound
  tenderness in the right lower quadrant. In
  addition, he has positive heel tap, Rovsing, and
  psoas signs. Contrast-enhanced CT of the abdomen
  and pelvis is performed (see Image A). What is
  the diagnosis?

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Discussion

• Although the patient's presentation is classic
  for appendicitis, he lacks some findings on
  review of systems. He was in no distress and
  afebrile, without any anorexia or vomiting.
  Initial CT of the abdomen showed a thickened
  terminal ileum a normal-appearing appendix and
  perimesenteric fat stranding, which was read as
  nonspecific inflammation of the bowel most
  consistent with regional enteritis. However,
  because his pain worsened over the next several
  hours, he was taken to the operating room for
  diagnostic laparoscopy. As shown on the
  intraoperative image (see Image B), a toothpick
  was found perforating the cecum. The toothpick
  was removed, and the patient had an uncomplicated
  recovery.

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• Toothpick ingestions are rare, but the literature
  includes several case reports. Approximately 70
  of patients with reported toothpick ingestions
  present with abdominal pain. However, only about
  12 remember ingesting the toothpick. The onset
  of symptoms varies, with a reported range of less
  than 1 day to 15 years after ingestion.
  Perforation frequently occurs at the duodenum
  and sigmoid, but this case shows it may occur
  anywhere. Imaging studies are useful in only 14
  of cases laparotomy is the most common method
  for definitive diagnosis. The overall reported
  mortality rate is as high as 18 (Li, 2002).
  Patients ingesting sharp objects and objects
  larger than 2 X 5 cm should be watched closely
  and treated aggressively.

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• This case reminds physicians that a CT may be
  bypassed in a patient with a surgical abdomen.
  Although the patient lacked some classic symptoms
  of appendicitis, the history and examination
  findings were consistent with a surgical abdomen.
  CT may have delayed the appropriate treatment,
  which was diagnostic laparoscopy.

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Gen-Path Uninethttp//pat.uninet.edu/zope/pat/c
asos/C144/index.html

• 18y Female Cervical lymphadenopathy

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Clinical Details

• Female, 18 years old with multiple right
  lateral-cervical lymph node painless enlargement
  lasting for more than one month, without any
  other clinical sympthoms. A lateral-cervical
  lymph node biopsy is performed.
• lymph node 1,5 cm in largest diameter. The cut
  surface shares regular yellow areas intermingled
  with normal appearing areas among them.

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44-year-old woman, previosly healthy, presented
with chest pain (right side), fever, cough and
mucoid expectoration. Physical examination was
unremarkable. Chest x-ray showed subpleural
nodular (6x4x4 cm) shadow in right lower lobe. A
lobectomy was performed.
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Subpleural Nodule Biopsy
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Sub pleural Cryptococcoma

• Cryptococcus neoformans is an encapsulated yeast,
  round or oval (3.5 to 8.0 microns).
• Narrow based budding is observed between the
  parent and daughter cells (blastoconidia or
  buds).
• Cryptococcus neoformans is the most common human
  pathogen.
• Four serotypes (A,B,C,D) of Cryptococcus
  neoformans A and D common.
• Cryptococcus neoformans classically is associated
  with desiccated pigeon feces, can be found in the
  feces of other birds.

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Discussion

• Inhalation of fungus leads to infection of the
  lungs.
• A transient colonization of airways or more
  extensive pulmonary involvement.
• May be self-limited or a progressive pulmonary
  disease.
• May disseminate to other sites common
  meningitis. 85 meningitis cases may not have
  pulmonary symptoms.
• The final result of pulmonary infection may be a
  cryptococcoma or a residual pulmonary nodule.

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35 Year male with Jaundice Weight
loss.http//path.upmc.edu/cases/case297.html
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History

• 35-year-old Asian man from Thailand.
• Jaundice, fatigue, Wt loss 15 pounds/2mon
• LFT - AST 121 IU/L, ALT 112 IU/L, ALP 539 IU/L,
  GGTP 570 IU/L, Bil Total 13.5 mg/dl, direct
  bilirubin 10.1 mg/dl.
• CT scan demonstrated 1) multiple hepatic and
  pulmonary lesions 2) dilatation of bilateral
  hepatic ducts and common bile duct with thickened
  walls and infiltration of periportal soft
  tissues 3) large volume of ascites 4)
  heterogeneous and nodular omentum

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Imaging Investigations

• Multiple hepatic and pulmonary lesions
• dilatation of bilateral hepatic ducts and common
  bile duct with thickened walls and infiltration
  of periportal soft tissues
• large volume of ascites
• heterogeneous and nodular omentum

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Imaging Investigations

• ERCP revealed multiple strictures in the intra-
  and extra-hepatic biliary system
• Tumor marker CA19-9 320,000 U (ref lt38.0 U)
• CEA 52 ng/ml (ref lt5 ng/ml).
• Alpha-fetoprotein - normal

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Bile and Ascitic fluid cytology

• clusters of small, yellow-brown, urn-shaped
  parasitic ova with a convex operculum resting on
  "shoulders" and a small knob at the opposite end.

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Bile fluid cytology

• loose clusters of atypical ductal epithelial
  cells
• Nucleomegaly, hyperchromasia, coarse chromatin
  and irregular nuclear membrane

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Final Diagnosis

• Cholangiocarcinoma, secondary to infection of
  liver flukes (Clonorchis sinensis or Opisthorchis
  viverrini).
• Humans are infected by eating raw or undercooked
  fish containing the encysted larvae
  (metacercariae).
• After excystation in the duodenum, the immature
  flukes enter the biliary ducts and differentiate
  into hermaphroditic adults which produce eggs
  released into feces ? snails ? Fish.
• The adult fluke has a life span of more than 20
  years, which explains persistent infection.