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Head/Neck/Endocrine Pathology
Wednesday, March 24, 7:30 PM
Maryland
Surgical Pathology of Unusual Head and Neck/Endocrine Lesions
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Moderator:
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MARY RICHARDSON
Medical University of South Carolina, Charleston, SC
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Disclosure:
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In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose. |
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Panelists:
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LESTER D.R. THOMPSON, Southern California Physicians Medical Group, Woodland Hills, CA
MANJU L. PRASAD, Yale University School of Medicine, New Haven, CT
DAVID N. LEWIN, Medical University of South Carolina, Charleston, SC
JENNIFER L. HUNT, Massachusetts General Hospital, Boston, MA
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Clinical Histories and Still Images are displayed below.
Click on slide thumbnail images for an enlarged view.
If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137.
Submitted by: Jennifer L. Hunt - Massachusetts General Hospital, Boston, MA
This is a 55 year old female with a known history of MEN 2A. She had a total thyroidectomy in 1976 for medullary carcinoma and bilateral adrenalectomy in 1977 for pheochromocytoma. In 2007, she had a new swelling in her neck and an increased calcitonin level. At surgery, she was found to have a 1.5 cm hard lymph node in the lower right jugular chain and a second node in the right central compartment. The lymph node is shown in the histologic slide.
Elevated calcitonin level
Case 1 - Slide 1
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Submitted by: Manju L. Prasad - Yale University School of Medicine, New Haven, CT
A 15 year-old boy presented with a submandibular mass on the left side of neck of approximately 3 months duration. He reported waxing and waning pain as well as intermittent episodes of swelling and regression of the mass. The patient denied fever, otalgia, numbness, change in voice or recent dental procedures. There was no prior significant history. Ultrasound showed a well defined, soft tissue mass measuring 3.3 x 3.1 x 2.6 cm with scattered calcifications and no evidence of cystic degeneration, hemorrhage or invasion (Fig. Case_2a_US). He underwent uneventful removal of an apparently encapsulated tumor that ‘shelled out' easily.
Macroscopice examination of the specimen showed a well circumscribed, tan white, rubbery, lobulated mass with slightly cut surface measuring 2.5 x 2.3 x 1.8 cm (Case_2b-Gross). Immunohistochemistry showed that the tumor cells were variably positive for cytokeratin (AE1:AE3), CAM5.2, p63, p16, S100, and CD117. Tumor cells were negative for calponin, smooth muscle actin, chromogranin, synaptophysin, CD34 and CD56. A high proliferative index (>50%) was noted with Ki-67. In-situ hybridization for Epstein Barr virus encoded RNA (EBER) was negative.
Case 2 - Slide 1
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Submitted by: David N. Lewin - Medical University of South Carolina, Charleston, SC
A 47 year old white male was seen for evaluation of a transient episode of abdominal pain, fever/chills, and mild jaundice with abnormal LFTs. He was seen by his local doctor and underwent an abdominal ultrasound which revealed a mild common and intrahepatic bile duct dilatation of unknown cause. The gallbladder itself was normal with no gallstones or signs of cholecystitis. This was followed by an abdominal CT scan which again showed biliary duct dilatation, but essentially no other abnormalities. At presentation to our institution one week later he was actually quite well with only minimal abdominal discomfort. He was no longer jaundiced, and had no further fever or chills. His appetite had returned and his weight remained stable. There was no alteration to his bowel habits. The review of systems was negative. His only significant history was of hypertension. Physical exam was unremarkable. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a filling defect proximal to the low cystic duct takeoff in the mid common bile duct. Intraductal ultrasound revealed a 6 x 14 mm lesion penetrating all three layers of the bile duct. 10% of the lesion was exophytic into the lumen of the bile duct. Bile duct brushings and biopsy were obtained which revealed atypical cells. Two weeks later the patient was taken to the operating room for a bile duct resection. The specimen was received in the frozen section room. Grossly there was diffuse thickening of the bile duct. The lesion was nodular, tan grey with focal brown-black pigmentation. A cross section of the bile duct lesion is provided for evaluation.
His bilirubin reached a peak of 4.0, and one week later returned to normal (0.9). The AST and ALT were abnormal, at 82 and 210 respectively, however also returned to normal 8 days later. The amylase and lipase were initially abnormal and similarly returned to normal 8 days later. His complete blood count and electrolytes are all completely normal. CEA was 1.5 (normal) and a CA19-9 was 51 (upper limit of normal 37).
Case 3 - Slide 1
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Submitted by: Lester D.R. Thompson - Southern California Permanente Medical Group, Woodland Hills, CA
A 73 year old man presented with an enlarging mass in the
left salivary gland. Radiographs showed extension into the
infratemporal fossa. He was otherwise healthy, without any
other abnormalities.
Case 4 - Slide 1
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