Head & Neck Case Review 2020-04

Head & Neck Case Review

April, 2020

History

A 19-year-old female presented with a rapidly enlarging 7.5 cm left-sided thyroid mass. Multiple, bilateral pulmonary nodules measuring up to 2 cm were present on CT scan, consistent with metastatic disease. She underwent total thyroidectomy and left neck dissection followed by radioactive iodine ablation. Images from the thyroid resection are shown below.

Images

Necrosis
Mitoses
TTF-1
Thyroglobulin
Calcitonin

Quiz

Q1. Which gene is most likely to harbor a mutation in this patient’s tumor?

  • A. BRAF
  • B. DICER1
  • C. RAS
  • D. TERT

Q2. The prognosis for this tumor type is better in young people than in older adults.

  • A. True
  • B. False

Diagnosis

Contributor

Rebecca Chernock, M.D.
Associate Professor
Department of Pathology and Immunology
Washington University in St. Louis

Head & Neck Case Review 2020-03

Head & Neck Case Review

March, 2020

History

The patient is a 57 year-old male with a history of recurrent nephrolithiasis for 20 years. Serum biochemistry revealed: PTH 11.5 pmol/L (reference range, 2.0 – 9.3 pmol/L) and calcium 2.62 (reference range 2.20 – 2.60 mmol/L). A diagnosis of primary hyperparathyroidism was made. Pre-operative localizing studies were not helpful in determining location of a parathyroid lesion. Bilateral neck exploration was undertaken with planned parathyroidectomy.

Intraoperative findings included: three normal-appearing parathyroid glands (which were biopsied) and a single markedly enlarged left superior parathyroid gland (which was easily resected without adhesions). Intraoperative post-resection serum biochemistry revealed: PTH 3.4 pmol/L.

Surgical pathology received biopsies of the three grossly “normal-appearing” parathyroid glands which showed normocellular parathyroid tissue on histology (not pictured). The excised parathyroid weighed 4.27 g (fresh) and measured 3.1 cm in greatest dimension (pictured).

Images

Virtual H&E slide

Quiz

Q1. Compared to a conventional parathyroid adenoma, the entity in this case

  • A. is associated with an increased risk of vascular invasion.
  • B. occurs secondary to renal failure/changes in renal function.
  • C. frequently shows an increased mitotic index.
  • D. is comparable in terms of prognosis.
  • E. does not result in hyperparathyroidism.

Q2. The amount of adipose tissue is directly proportional to the body mass index of this patient.

  • A. True
  • B. False

Diagnosis

Contributor

Stephen M. Smith, MD
Assistant Professor, Division of Anatomic Pathology
Department of Laboratory Medicine & Pathobiology
The University of Toronto/University Health Network

Head & Neck Case Review 2020-02

Head & Neck Case Review

February, 2020

History

A 73-year-old man presented with right nasal obstruction and epiphora for about a year. On nasal endoscopy a smooth submucosal mass attached to the anterior part of the inferior turbinate and extending to the septum was identified. CT imaging also confirmed the presence of an ill-defined soft tissue mass confined to the nasal cavity. The patient subsequently underwent resection. H&E slides and immunostains are shown. The following stains were negative: cytokeratin AE1/AE3, CD34, S-100, SOX10, and myogenin.

Images

Virtual H&E slide

Quiz

Q1. The following genetic syndromes have been associated with this disease in children except:

  • A. Li-Fraumeni syndrome
  • B. Costello syndrome
  • C. Neurofibromatosis type 1
  • D. Beckwith-Wiedemann syndrome
  • E. Cowden syndrome

Q2. The most common site of disease outside the Head and Neck is the paratesticular region.

  • A. True
  • B. False

Diagnosis

Contributor

Mitra Mehrad, M.D.
Assistant Professor
Department of Pathology, Microbiology and Immunology
Vanderbilt University Medical Center, Nashville, TN

Head & Neck Case Review 2020-01

Head & Neck Case Review

January, 2020

History

A 74-year-old woman presented with respiratory failure. The patient had a 3-month history of cough and progressive dyspnea with rapidly increasing neck swelling. CT Imaging revealed massive thyromegaly and lymphadenopathy with metastases to the lung, liver, kidney, and iliac bone. Patient underwent thyroid surgical resection to relieve the airway compression. Gross examination of the thyroid showed diffuse replacement by multiple masses, the largest measuring 7.6 × 5.3 × 2.7 cm, with infiltrative borders and extension into surrounding adipose tissue. H&E slides and immunostains are shown.

Images

Virtual H&E slide

Quiz

Q1. What is the characteristic genetic alteration in this tumor?

  • A. t(12;15)(p13,q25) ETV6-NTRK3
  • B. t(2;22)(q33;q12) FEV-EWS
  • C. t(11;19)(q21;p13) CRTC1-MAML2
  • D. BRAF V600E mutation

Q2. Adjuvant therapy with radioactive iodine would be effective.

  • A. True
  • B. False

Diagnosis

Contributor

Mitra Mehrad, M.D.
Assistant Professor
Department of Pathology, Microbiology and Immunology
Vanderbilt University Medical Center, Nashville, TN