21 yo male with Right adrenal mass

Adrenal
MS03-7868
21 yo male with Right adrenal mass

Diagnosis:
CORTICAL CARCINOMA
CLINICAL- 1:1x 10^6 bimodal-kids & mid age. *Abdominal pain, ~mass
~Cusing's or mixed sx
GROSS- >100g, nodular, red-brown (if sex hormone producing, yellow (if Cushing's) +/- necrosis, bleeding, calcifications
HISTO- alveolar, trabecular, or solid groups of cells w/ eosinophilic or vacuolated cytoplasm w/ variable nuclear pleo. +/- pseudoinclusions. Incresed mits.
IHC- CK-, vimentin+, SYN +/-, CHROM -
DDX- adenoma-
Less than 2 are non-metastatic/ Greater than 4 metastatic or recurrent:
-venous, capsular, or sinusoidal invasion
-pleomorphic (Fuhrman III/ IV) nuclei
-<25% clear cells5 mits per 50 hpf)
-diffuse architecture
Another study showed worst behavior if
-broad fibrous bands
-necrosis

-78.3g
-3 histo criteria (venous, clear cells, diffuse architecture)

68 yo Black female with hypertension

Adrenal
AU00-43-4
68 yo Black female with hypertension. Autopsy done after "sudden death"

Diagnosis:
NONFUNCTIONAL CORTICAL ADENOMAS AND CORTICAL NODULES
CLINICAL- Incidental findings, but more common in elderly, DM, HTN
GROSS- usually multicentric or bilateral & bright yellow +/- fibrous capsule (esp large). Black (when in reticularis)
HISTO- fasiculata cells compose nodules with non-adenomatous cortex NOT atrophied.

http://www-user.yokohama-cu.ac.jp/~byori2/PathologyLab2001/LaboratoryWork/CONTENT/Legends.html
http://www-user.yokohama-cu.ac.jp/~byori2/PathologyLab2001/LaboratoryWork/CONTENT/07Endocrine.html

29 year old with Stage IB cervical cancer.

MS93-12306-32
Cervix
1 H&E slide
29 year old with Stage IB cervical cancer.

Diagnosis: Invasive, moderately-differentiated adenocarcinoma, with focal areas of squamous differentiation (adenosquamous carcinoma)

31 year old woman with a large ovarian mass

MS91-12477
Ovary
1 H&E, 1 Pap, 1 DQ
The patient is a 31 year old woman with a large, 2080 gram, predominantly solid, right ovarian mass with soft, somewhat lobulated, tan cut surfaces.



Diagnosis: Dysgerminoma 未分化胚細胞腫
未分化胚細胞腫［ミブンカハイサイボウシュ］
【英】dysgerminoma
【独】Dysgerminom
《同義語》卵巣精上皮腫ovarian seminoma
卵巣の原始胚細胞由来の悪性腫瘍．組織学的に精巣のセミノーマ＊seminomaと鑑別できない．80％は20歳から30歳代に，5％は10歳未満に発生する．卵巣癌＊の5～13％，妊娠中の卵巣悪性腫瘍の20～30％を占める．5～10％は両側性，まれに性腺の異常をみることがある．腫瘍は充実性，割面は灰白色を呈し，ときに出血や壊死を伴う．細胞は大型，円形で，充実性の胞巣ないし索状配列を示す．核は丸く，細胞の中心に位置し，細胞質は淡白でグリコ〔ー〕ゲンやアルカリホスファターゼ反応が陽性．間質の量はさまざまだが，リンパ球の浸潤が特徴的であり，50％はサルコイド様の肉芽を形成する．まれに合胞体性絨毛上皮細胞や性腺細胞を含み，それぞれHCGやステロイドホルモン＊を分泌することがある．放射線感受性が高く，5年生存率は60～90％，20歳未満や腫瘍の直径が15cm以上のときは再発しやすい．

http://www.yamagiku.co.jp/byouri/syourei/syourei61.htm

A 35-year-old Oriental man complained of...

10-F93

Case 10.
A 35-year-old Oriental man complained of painless swelling in the region of his parotid gland, of several moths' duration. Physical examination disclosed a mass at the angle of the jaw which appeared to involve the superficial lobe of the parotid gland. A fine needle aspiration cytology specimen yielded a few malignant cells interpreted as suspicious for lymphoma. Because a definitive diagnosis could not be made, a superficial parotidectomy was performed.


Dx: malignant lymphoepithelial lesion (Undiff. Ca)
- similar to undifferentiated nasopharyngeal Ca associated non-neoplastic lymphoid component.

DDx: NH lymphoma

IHC: cytokeratin (+), LCA (-)

59 year old man with a 9 cm tan/brown renal mass.

MS96-8279 (1 slide) KIDNEY
Clinical: 59 year old man with a 9cm tan/brown renal mass.

DX: Renal cell carcinoma, granular cell type, nuclear grade 2 of 4
Confined to kidney, no lvs inv, margins free, tumor size 9.0 cms

Comment: The pure granular cell variant accounts for 7% of renal cell carcinomas. Cells with eosinophilic granular cytoplasm are often a component of higher grade clear cell rcca. Granular cell carcinomas tend to be o higher nuclear grade than clear cell renal cell ca. They behave and are treated identically stage for stage.
Grossly, the mitochondria-rich cells impart a brown color to the tumor.
(if these nuclei had more prominent nucleoli, it could easily pass for a grade 3 lesion)

83year old man with a 2 x 2 cm renal mass and...

MS95-1066 (1 slide) KIDNEY

Clinical: 83year old man with a 2 x 2 cm renal mass and a large paracaval lymph node.

DX: Renal cell carcinoma, sarcomatoid variant, grade 4 of f (Fuhrman)

Comment: The sarcomatoid variant is often high grade. It is unusual for a small renal cell carcinoma to metastasize, but this one was also found in his node.

61 year old white man with multiple nodules...

MS96-14954 (1 slide) KIDNEY

Clinical: 61 year old white man with multiple nodules in the right kidney.

DX: Renal cell carcinoma, clear cell type, nuclear grade 2 of 4 (Fuhrman)
Comment: Clear cell type represents approx. 70% of RCCs. They are multicentric in only 4% of cases. An alveolar pattern with nests of clear cells separated by thin, vascular septae is typical.

FUHRMAN GRADING SYSTEM

Characteristics
I Nuclei round, uniform, approximately 10 micro-meters; nucleoli inconspicuous or absent
II Nuclei slightly irregular, approximately 15 micro-meters; nucleoli evident
III Nuclei very irregular, approximately 20 micro-meters; nucleoli large and prominent
IV Nuclei bizarre and multilobated, 20 micro-meters or greater; nucleoli prominent; chromatin clumped
(Stage is most important, but grade also correlates with survival.)

49 year old woman with bilateral renal masses...

MS96-9955 (2slides)
KIDNEY

Clinical: 49 year old woman with bilateral renal masses who undergoes bilateral partial nephrectomies.



DX: #2 Papillary renal cell carcinoma (3.0cm)
#3 Renal papillary neoplasm of low malignant potential (2.0cm) see insert from report

Comment: The nomenclature of small renal cell neoplasms is not well sorted out at this time. Adenoma vs LMP vs small carcinoma is debated. Some call ALL renal cell neoplasms malignant because there are examples of small lesions that have metastasized in large series. Epstein prefers LMP for lesions smaller than 3.0 cms with no malignant features i.e., invasion, necrosis, hemorrhage or porminent atypia. Keep in mind that all stage 1 renal cell neoplasms are treated with surgery only, so calling a small benign appearing lesion a cortical adenoma or a small renal cell carcinoma won't affect treatment.

(insert)
Small lesions.
The diagnosis of renal cell lesions under 3 cm in diameter has been controversial. Most lesions under 3cm behave in a benign fasion. However, it is well documented that some lesions under 3cm will metastasize, although these cases may represent less than 5% of this group of lesions. We consider a non-oncocytic stage I, nuclear grade 1 or 2 lesion that is less than 3cm to be a renal cell lesion of low malignant potential, but would diagnose any tumor of higher stage or nuclear grade as carcinoma.
Review article Am. J. Clin. Path. 1995;103:624-635

54 year old woman with a left renal mass.

MS96-8408 (1 slide)
Clinical: 54 year old woman with a left renal mass.

DX:Renal cell carcinoma, predominantly clear cell, with focal sarcomatoid diff
Marked granulomatous inflammation
Comment: Clear cell, granular cell and sarcomatoid are different patterns of the "usual type" of renal cell carcinoma. Chromophobe carcinoma and papillary renal cell ca are ultrastructurally and cytogenetically distinct from the usual types of RCCa.
The sarcomatoid variant typically presents as a higher grade lesion, but probably behaves similarly stage for stage and grade for grade.
Remember to grade the nuclei of all renal cell carcinomas as the highest found, even if it's only the smallest focus.
The granulomatous inflammation is a curiosity. Stains for bugs were neg.