Head & Neck Case Review 2021-04

Head & Neck Case Review

April, 2021

History

A 68-year-old African American male presented with a nontender mass under his tongue for 2 weeks. He had dysarthria because of compromised tongue movement. He denied pain, bleeding, dysphagia, loss of appetite, weight changes, and shortness of breath. There was no history of prior swelling, trauma, or oral cavity surgeries. Clinical examination revealed a mobile, solid, non-tender, oval-shaped right sublingual mass (3.0 x 2.0 cm). No notable cervical adenopathy was found.

CT scan showed a well-circumscribed, oblong shaped hyperdense mass (4.1 x 2.5 x 4.0 cm) situated within the floor of mouth/right sublingual gland with mild mass effect upon the midline intrinsic tongue musculature. No calcification or sialolith were identified. There was no surrounding inflammation or cervical lymphadenopathy. Excision of the mass was performed.

Images

Quiz

Q1. Which genetic alteration is associated with this tumor?

  • A. SS18-SSX1/SSX2/SSX4 fusion
  • B. EWSR1-FLI1 fusion
  • C. NAB2-STAT6 fusion
  • D. PLAG1 rearrangement

Q2. Histologic features of the tumor always predict outcome in these patients.

  • A. True
  • B. False

Diagnosis

Contributors

Shajia Ansari, MD
Resident
Pathology and Immunology
Baylor College of Medicine
Houston, TX US

Syeling Lai, MD
Associate Professor
Pathology and Immunology
Baylor College of Medicine
Houston, TX US

Head & Neck Case Review 2021-02

Head & Neck Case Review

February, 2021

History

A 65 year-old male with no significant past medical history presents with fatigue, difficulty swallowing, and voice changes for several months duration. CT scan showed an 8 cm left-sided neck mass. The patient underwent left hemithyroidectomy and parathyroidectomy. CT imaging, H&E sections, and immunostains of the mass are shown.

Images

Quiz

Q1. All of the following are characteristic features of this tumor, EXCEPT:

  • A. Invasive growth involving adjacent structures
  • B. Vascular and/or perineural invasion
  • C. Nodular growth pattern with broad bands of fibrous connective tissue
  • D. Rare recurrence after resection

Q2. CDC73 mutation is the molecular driver in the pathogenesis of this tumor.

  • A. True
  • B. False

Diagnosis

Contributor

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

Head & Neck Case Review 2021-01

Head & Neck Case Review

January, 2021

History

An 80-year-old female with a history of squamous cell carcinoma of the tongue that was treated by hemiglossectomy presented a year later with a tender right neck mass. A right radical neck dissection was performed, consisting predominantly of matted cervical lymph nodes with necrosis. In addition, Level IB contained a 3.0 cm well circumscribed, firm, tan-pink mass, shown below.

Images

Quiz

Q1. The histologic features are consistent with:

  • A. Sjogren syndrome
  • B. Atypical lymphoproliferative disorder
  • C. Chronic sclerosing sialadenitis
  • D. Chronic sialadenitis
  • E. Castleman disease

Q2. Which statement is TRUE about this disease?

  • A. It is considered an IgG4-related disease.
  • B. Fine needle aspiration of salivary gland can be diagnostic.
  • C. It can result from compression by an adjacent tumor.
  • D. Obliterative phlebitis is a characteristic feature.
  • E. Lymphoepithelial lesions are characteristic features.

Diagnosis

Contributors

  1. F. Zahra Aly, M.D., Ph.D., Clinical Associate Professor, Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine
  2. Saja Alramadhan, BDS, PGY-3 Resident, Department of Oral and Maxillofacial Pathology, University of Florida College of Dentistry
  3. Nada Al Qaysi, MD, PGY-4 Resident, Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine

Head & Neck Case Review 2020-12

Head & Neck Case Review

December, 2020

History

A boy presented to the pediatric otolaryngology clinic with a chief concern of mass in his left neck of several months’ duration.  He was also experiencing mild intermittent pain. There was no lymphadenopathy. Pre-operative imaging studies identified an intraparotid nodule.  A superficial parotidectomy was performed. H&E sections of the nodule are shown.

Images

Quiz

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

  • A. MAML2
  • B. NR4A3
  • C. PLAG1
  • D. PTEN

Q2. This tumor type is associated with a considerable rate of recurrence.

  • A. True
  • B. False

Diagnosis

Contributor

Jiancong Liang, MD PhD
Assistant Professor
Department of Pathology, Microbiology and Immunology
Vanderbilt University Medical Center, Nashville, TN

Head & Neck Case Review 2020-11

Head & Neck Case Review

November, 2020

History

A 58-year-old woman presented to her physician with a chief concern of mass of her anterior neck, of several years’ duration.  She was also experiencing dysphagia and hoarseness.  Review of her medical history revealed no medical conditions or medications.  The patient had smoked cigarettes for many years.  The mass was firm to palpation.  It was centered in the thyroid gland and was fixed to underlying anatomic structures, per radiographic evaluation.  At the time of presentation, the patient was euthyroid.  A total thyroidectomy was performed, with suspicion for a malignant process.

Images

Quiz

Q1.

  1. Given the histologic findings, which additional laboratory test would be most beneficial in evaluation of this patient?
  • A. PTH
  • B. RET status
  • C. Serum IgG4
  • D. Serum thyroglobulin

Q2. What is the vascular alteration characteristic of this disease process?

  • A. Vasculitis
  • B. Superior vena cava syndrome
  • C. Thrombosis
  • D. Occlusive phlebitis

Diagnosis

Contributors

Anne C. McLean-Holden, DMD, MS: Emory University Hospital, Atlanta, GA

Justin A. Bishop, MD: University of Texas Southwestern Medical Center, Dallas, TX

Head & Neck Case Review 2020-10

Head & Neck Case Review

October, 2020

History

A middle-aged man presented with a palpable neck mass and was found to have a complex 8.5 cm mass arising from the left thyroid lobe. He had no notable past medical history and no history of radiation exposure. The patient underwent hemithyroidectomy, with negative margins. Following resection, staging PET/CT/ultrasound did not demonstrate any other lesions.

Two months after hemithyroidectomy, the patient developed neck and supraclavicular swelling. PET/CT demonstrated a mass in the surgical bed extending into the mediastinum, as well as nodules in the contralateral platysma, sternocleidomastoid muscle, and supraclavicular region. A fine needle aspiration was performed of a palpable supraclavicular nodule. Images from the supraclavicular fine needle aspiration and thyroid resection are shown.

Images

Quiz

Q1. Which genetic alteration has been associated with this tumor?

  • A. BRAF V600E mutation
  • B. DICER1 mutation
  • C. RET-PTC3 fusion
  • D. Isochromosome 12p
  • E. PIK3CA mutation

Q2. Tumors occurring in infants and children generally have a favorable prognosis.

  • A. True
  • B. False

Diagnosis

Contributor

Margaret Compton, MD
Assistant Professor
Department of Pathology, Microbiology and Immunology
Vanderbilt University Medical Center, Nashville, TN

Head & Neck Case Review 2020-08

Head & Neck Case Review

August, 2020

History

A 30 year old patient presented with a pathologic mandible fracture and loose teeth following minimal trauma. CT imaging revealed a thin mandibular body and ramus with superimposed areas of permeative destruction and erosion, and a minimally displaced fracture of the mandibular angle. The ipsilateral maxillary sinus appeared hypoplastic. A segmental mandibulectomy with reconstruction was performed. The disease progressed within one year requiring total mandibulectomy and prosthetic replacement.

Images

Maxilla (left) / Mandible (right)
D2-40

Virtual Slide

https://pathpresenter.net/#/public/display?token=dd296748

Quiz

Q1. What is the diagnosis

  • A. Paget disease
  • B. Gorham-Stout disease
  • C. Angiosarcoma
  • D. Fibrous dysplasia

Q2. What are the characteristic histologic features?

  • A. Malignant lymphatic or vascular proliferation involving bone
  • B. Benign lymphatic or vascular proliferation and osteolysis
  • C. Cystic spaces lined by fibrous tissue with osteoclast-like giant cells
  • D. Osteonecrosis with a reactive lymphatic or vascular proliferation

Diagnosis

Contributor

Manuel Lora Gonzalez, MD
Selective Surgical Pathology (Head and Neck) Fellow, PGY-6
Department of Pathology and Immunology
Washington University in St. Louis

Head & Neck Case Review 2020-07

Head & Neck Case Review

July, 2020

History

A 19-year-old male presented for initial dental examination upon entering the armed forces. His medical history was non-contributory, and he was asymptomatic. Panoramic radiographic examination (below) revealed a radiolucency of the anterior mandible. The lesion was vaguely multilocular with a corticated and smooth border and crossed the midline. Mild clinical expansion was noted. An incisional biopsy was performed, and the findings are represented in the photomicrographs below.

Images

Quiz

Q1. This lesion is most often found in which area of the jaws?

  • A. Anterior mandible
  • B. Posterior mandible
  • C. Anterior maxilla
  • D. Posterior maxilla

Q2. The radiographic features in this case are suggestive of malignancy.

  • A. True
  • B. False

Q3.  This tumor does not have a known association with Carney complex.

  • A. True
  • B. False

Diagnosis

Contributors

Anne C. McLean-Holden, DMD1; Brenda L. Nelson, DDS, MS2

1University of Texas Southwestern Medical Center, Dallas, Texas, USA

2Naval Medical Center San Diego, San Diego, California, USA

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