CASE STUDIES PART 2

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CASE STUDIES PART 2

• Neoplasia

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Adenoma
Stalk
Slide 1There is a solitary mass attached via a long stalk to the colonic mucosa. It is discreet and does not involve the wall of the colon. The surface is dark red (hemorrhagic). The stool guaiac was positive.
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Polyp
Slide 2This 58 year old male had a routine physical examination with rectal examination. A stool guaiac was positive. Barium enema revealed a mass lesion in the descending colon that constricted the lumen. Note the tan, encircling tumor that erodes the mucosa and narrows the lumen.
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Apple Core
This barium enema with the patient in a lateral
position (head toward the right of the image)
demonstrates two encircling masses, one in the
transverse colon and one in the descending colon.
These are typical adenocarcinomas.
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Slide 3This is an adenocarcinoma of the cecum which demonstrates an exophytic growth pattern, as the bulk of the mass is within the bowel lumen. The patient had iron deficiency anemia.
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Fibroids Leiomyoma (Leiomyosarcoma if malignant)
Slide 4On physical examination, the uterus of this 35 year old female with menometrorrhagia was enlarged and irregular. There are multiple, discreet tumor masses arising in the myometrium but impinging upon both endometrial and serosal surfaces. These masses are firm and white to tan on sectioning.
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Slide 5This tumor was found in a 60 year old male with a long history of smoking after he developed hemoptysis. This is a large, friable, tan, firm mass which metastasized to hilar lymph nodes. Areas of tumor necrosis with cavity formation are present, and there is a pneumonia distal to the tumor from obstruction.
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Slide 6The tumor grew to a large size before it first manifested itself through hematuria. Note the yellowish areas (are clear cell areas microscopically) which are mixed with white areas (fibrous tissue), red areas (very vascularized tumor), and brown areas (tumor without a clear cell pattern).
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Slide 7The liver is filled with multiple masses of varying size. The primary was a colonic adenocarcinoma. Some of the larger metastatic nodules have central necrosis.
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Osteosarcoma
Slide 8Sarcomas arise in tissues derived embryologically from mesoderm (bone, cartilage, muscle, soft tissue). This mass arises in the femur in a young person (note the epiphysis).
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Slide 9A small breast mass was noted on routine mammography in a 40 year old woman. The mass was located radiographically prior to surgery and marked with blue dye to facilitate finding it for removal. It is very discreet, firm, and homogenous.
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Endometrial hyperplasia
Slide 10This woman was taking estrogen, which led to growth of the endometrium into the large folds seen here. This process is diffuse. Hyperplasia is a reversible process, but it may represent a "preneoplastic" condition in some cases.
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Case 1

• History
• This was an incidental finding in a 15 year old
  girl that was found at the time of appendectomy.
  A discreet yellow mass was observed in the small
  bowel wall and was resected.

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Fat
Slide 1.1The low power microscopic appearance of the mass is shown here.
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Slide 1.2The high power microscopic appearance of the mass is shown here.
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Questions

• 1. What is the degree of differentiation?
• 2. What is the malignant counterpart of this
  lesion?

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Case 1 Lipoma

• Answers
• What is the degree of differentiation?
• This neoplasm is extremely well-differentiated,
  as it resembles normal adipose tissue. It is
  completely benign. In general, the degree of
  differentiation is helpful in grading a neoplasm.
  In general, the better differentiated a tumor,
  the lower grade it is.
• What is the malignant counterpart of this lesion?
  
• Liposarcoma. Such a neoplasm would most likely
  be found in deep soft tissues in thigh or
  retroperitoneum. Lipomas can be found in a
  variety of locations and are generally small.

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_at_ Case 2 (pg 299 for lecture)

• History
• A 52 year old woman underwent a hysterectomy
  because she had irregular menstrual bleeding. At
  surgery, the uterus appeared nodular (as in
  kodachrome slide 4 above). In surgical pathology
  on dissection, the nodules were firm, white,
  discreet, and arose in the myometrium.

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Bundles of muscle fibers forming leiomyoma
Normal
Slide 2.1The low power microscopic appearance of one of the masses is shown here.
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Smooth Muscle
Slide 2.2The high power microscopic appearance of one of the masses is shown here.
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Questions

• 1. If multiple tumor masses are present, then why
  isn't this metastatic?
• 2. What is the malignant counterpart of this
  lesion and does it often arise from leiomyoma?

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Case 2 Leiomyoma of uterus

• Answers
• If multiple tumor masses are present, then why
  isn't this metastatic?
• This is an example of multicentric origin of a
  neoplasm within an organ. The benign nature of
  these neoplasms is confirmed histologically. Each
  individual tumor is benign. Malignant tumors can
  also sometimes be multicentric in origin, but in
  general there is usually a single primary tumor
  from which metastases originate.
• What is the malignant counterpart of this lesion
  and does it often arise from leiomyoma?
• Leiomyosarcoma. Such malignant smooth muscle
  tumors usually arise de novo. Although about one
  out of every five or six women has a leiomyoma,
  leiomyosarcomas are rare.

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Case 3

• History
• A 61 year old farmer began complaining of vague
  chronic abdominal pain. This was associated with
  a 20 lb weight loss over several months.
  Endoscopy revealed an irregular area of shallow
  ulceration on the lesser curvature of the
  stomach. This area was biopsied and showed
  adenocarcinoma. At surgery, exploration of the
  abdomen revealed an area of diffuse, firm
  thickening of the stomach wall.

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Lesion
Lumen
Slide 3.1The low power microscopic appearance of the mass is shown here.
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Adenocarcinoma metastasizing
Slide 3.2The high power microscopic appearance of the mass is shown here.
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Questions

• Why is the cancer accompanied by weight loss?
• 2. How has the incidence of stomach cancer
  changed in the U.S. in this century?

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Case 3 Adenocarcinoma of stomach

• Answers
• Why is the cancer accompanied by weight loss?
• Malignant neoplasms are often accompanied by
  weight loss. This may be from loss of appetite
  (nausea, feelings of abdominal fullness),
  increased metabolic demand, or by interference
  with eating or digestion. In general, the greater
  the weight loss, the worse the prognosis.
• How has the incidence of stomach cancer changed
  in the U.S. in this century?
• Gastric adenocarcinoma has decreased in
  incidence. It remains high in Japan.

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Case 4

• History
• A 73 year old woman from Salt Lake City underwent
  mammography. Both her mother and a maternal aunt
  died of breast cancer. The mammogram revealed a
  poorly defined mass in the left breast. A
  mastectomy was performed.

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Duct
Malignant Tumors
Slide 4.1The low power microscopic appearance of the mass is shown here.
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Tumor getting into channels
Slide 4.2The medium power microscopic appearance of the mass is shown here.
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Slide 4.3The low power microscopic appearance of the skin is shown here.
No surgery, too late. Causes inflammation.
(orange peel on the skin)
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Tumor blocking lymph
Slide 4.4The high power microscopic appearance of the skin is shown here.
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Questions

• 1. What is the significance of the history of
  breast cancer in the family?
• 2. What is the degree of differentiation?
• 3. What methods are available for diagnosis of
  the mammographic lesion to determine if
  mastectomy should be performed?

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Case 4 Infiltrating ductal carcinoma of breast

• Answers
• What is the significance of the history of breast
  cancer in the family?
• A maternal family history of breast cancer
  (mother, aunt, sister) suggests an increased risk
  of breast cancer for the patient.
• What is the degree of differentiation?
• This neoplasm is moderately differentiated. The
  neoplastic cells are attempting to make
  ill-defined ducts.
• What methods are available for diagnosis of the
  mammographic lesion to determine if mastectomy
  should be performed?
• Needle aspiration biopsy can be done for
  cytologic diagnosis. An excisional biopsy will
  yield more tissue for definitive diagnosis and
  for hormone receptor assay if malignant.

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Case 5

• History
• An 82 year old woman was admitted in severe
  respiratory distress. History revealed that she
  had undergone mastectomy seven months previously.

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Breast cancer to the lung
Slide 5.1The low power microscopic appearance is shown here.
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Cancer
Slide 5.2The high power microscopic appearance is shown here.
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Questions

• 1. What are typical routes for metastases? How do
  these routes differ in regard to the primary site
  and cell of origin?
• 2. How did the metastases account for the
  clinical presentation?

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Case 5 Metastatic breast carcinoma in lung

• Answers
• What are typical routes for metastases? How do
  these routes differ in regard to the primary site
  and cell of origin?
• Carcinomas often spread via lymphatics to
  regional lymph nodes. The primary site will
  determine which nodes are affected--thus enlarged
  hilar nodes suggest a lung primary, axillary
  nodes a breast primary, cervical nodes a head
  neck primary, etc. Carcinomas may also spread
  locally by direct extension, to distant sites via
  the bloodstream, and by seeding through body
  cavities. Sarcomas are less likely to use
  lymphatic spread and more likely to use
  hematogenous spread.
• How did the metastases account for the clinical
  presentation?
• The metastases occluded vascular channels in the
  lung (tumor emboli), leading to an appearance
  similar to pulmonary embolization. If larger
  metastatic lesions are present, they can
  compromise lung function by simply reducing lung
  capacity or obstructing bronchi.

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Case 6

• History
• A 38 year old woman had heavy, irregular
  menstrual bleeding. She was treated with
  endometrial curretage followed by hysterectomy.

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Endometrial Hyperplasia
Slide 6.1The microscopic appearance of the lesion is shown here.
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Questions

• 1. What is the significance of hyperplasia in
  this setting?
• 2. How does hyperplasia differ from neoplasia?

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Case 6 Endometrial hyperplasia (Benign)

• Answers
• What is the significance of hyperplasia in this
  setting?
• This could represent a preneoplastic condition.
• How does hyperplasia differ from neoplasia?
• The hyperplasia is potentially reversible,
  whereas a neoplasm is autonomous growth.
  Sometimes the distinction is difficult to make on
  a small biopsy sample or on cytology. The
  hyperplasia could be "atypical" and show changes
  similar to that of a neoplasm. Conversely, a
  neoplasm could be well-differentiated and
  resemble normal or hyperplastic tissue.

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Case 7

• History
• A 49 year old male had a 100 pack/year history of
  smoking. He had a chronic cough, but recently he
  noted some blood-streaked sputum. A chest x-ray
  showed a hilar shadow. After clinical work-up,
  the tumor that was found was not amenable to
  resection. He died soon after initiation of
  radiation therapy.

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Squamous cancer
Slide 7.1The low power microscopic appearance of the mass is shown here.
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Squamous lung cancer
Slide 7.2The medium power microscopic appearance of the mass is shown here.
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High Grade
Slide 7.3The high power microscopic appearance of the mass is shown here.
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Questions

• 1. What caused this cancer?
• 2. Where would this tumor metasatasize first?
• 3. What methods are available for diagnosis of
  this neoplasm?

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Case 7 Squamous cell carcinoma of lung

• Answers
• What caused this cancer?
• Smoking.
• Where would this tumor metasatasize first?
• Hilar lymph nodes. It could also later spread to
  the pleura and chest wall locally. Distant
  metastases could include sites such as the
  opposite lung, adrenal, bone marrow, and brain.
• What methods are available for diagnosis of this
  neoplasm?
• Sputum cytology, bronchoalveolar lavage,
  transbronchial biopsy, open lung biopsy (in
  increasing order of invasiveness) for histologic
  diagnosis. Radiographic procedures can be used
  initially to determine if a mass is present and,
  if so, where to sample tissue.

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Case 8 null

• History
• This 12 year old male noted pain in the left
  lower leg, even at night, for several months
  following a blow to the calf from a soccer ball.
  A radiograph revealed a mass lesion involving the
  metaphysis of the distal femur.

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Bone cancer
Slide 8.1The low power microscopic appearance of the mass is shown here.
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Slide 8.2The medium power microscopic appearance of the mass is shown here.
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Tumor
Slide 8.3The high power microscopic appearance of the mass is shown here.
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Questions

• 1. Patients often equate a history of trauma with
  appearance of a neoplasm. How often is trauma the
  etiology for a neoplasm?
• 2. How can you tell that this neoplasm is arising
  in bone? What methods are available to determine
  the cell of origin?

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Case 8 Osteosarcoma of bone

• Answers
• Patients often equate a history of trauma with
  appearance of a neoplasm. How often is trauma the
  etiology for a neoplasm?
• Trauma is not considered to be an etiology for
  neoplasia.
• How can you tell that this neoplasm is arising in
  bone? What methods are available to determine the
  cell of origin?
• Radiographic procedures can show the location
  and appearance of the neoplasm and what tissues
  are involved. Radiographs can be correlated with
  the histologic appearance. If the tumor is making
  osteoid, then it is probably primary to bone.
  Further histologic studies could include
  immunoperoxidase staining (such as an
  immunoperoxidase stain for vimentin to show a
  mesenchymal origin, as opposed to a stain for
  cytokeritin that would detect tumors of
  epithelial origin). Electron microscopy is
  sometimes helpful in distinguishing neoplasms of
  epithelial origin (withe desmosomes), melanomas
  (with melanosomes), and lymphomas.

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Heres the next installment. Good Luck!