An 81 yof has had a left parotid mass for the last few months

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LOYOLA UNIVERSITY

MEDICAL CENTER

IRAP

APRIL 23, 2012

Case 1: EBV Positive Large B-cell Lymphoma of the Elderly

Lu Wang MD, Girish Venkataraman MD, Swati Mehrotra, MD

Clinical History: An 81-year-old female noticed an enlarging nodule in the left parotid region for the past few months. She was otherwise asymptomatic. Her past medical history was significant for left breast cancer s/p lumpectomy and axillary lymph node dissection in 2004. At Loyola, physical examination showed a 6-cm tender, left parotid mass encompassing the entire parotid. After an initial fine needle aspiration, she underwent total parotidectomy.

Diagnosis: EBV positive large B-cell lymphoma of the elderly (WHO 2008)

Differential Diagnosis:

• Classical Hodgkin Lymphoma (cHL)

• T-cell/Histiocyte-Rich Large B-Cell Lymphoma (T/HRLBCL)

• Anaplastic Large Cell Lymphoma (ALCL)

• Angioimmunoblastic T-Cell Lymphoma (AITL)

• EBV Positive Large B-Cell Lymphoma of the Elderly

• Lymphomatoid Granulomatosis (LyG)

Key Microscopic Features:

• Extranodal location with effaced architecture. May have large area of geographical necrosis

• Atypical B-cells with a spectrum in cell size, including many large transformed cells/immunoblasts and HRS-like giant cells

• Tumor cells expressing variably strong CD20, CD30 and EBV-LMP, and negative for CD15

• Tumor cells are not angiocentric

Discussion:

• Need to recognize this disease entity as a close mimic of cHL

• Remember to do EBER in cases with:

• Extranodal location

• DLBCL in older patients (>50yrs of age)

• Any polymorphous atypical (nodal/extranodal) lymphoid infiltrate

• Pattern of EBER positivity (small vs large vs both) is critical in making the distinction with cHL.

References:

1. Dojcinov SD, Venkataraman G. Jaffe ES et al. Blood 2011 May 5;117(18):4726-35.

2. Shimoyama, Y. Pathology International 2009; 59: 835–843

3. Shimoyama, Y. Cancer Sci. 2008; 99 (6): 1085-91

4. Swerdlow, SH, et al WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues (2008) ISBN 978-92-832-2431

Case 2: Cellular Schwannoma

Ugur Ozerdem, M.D., PGY-3, John M. Lee, M.D., Ph.D.

Clinical History: 41 year-old woman presented in July 2010 with back and left shoulder pain. She had occasional numbness in her left chest, back and arm and had weakness in her left lower extremity as well. MRI showed a 3.8 cm left C7-T1 intradural extramedullary neoplasm extending from neural foramen into the spinal canal. Subsequently, she had a C7-T2 laminectomy with partial left T1/2 resection of the tumor. Fourteen months after the initial resection, her symptoms recurred; including left upper extremity numbness and decreased sensation in the left trunk, and the 4th and 5th digits of the left hand. A follow-up MRI of cervical/thoracic spine showed an increase in size of the residual tumor to 4.8 cm. Tumor has been re-resected with left thoracic T1-T2 extracavitary approach. A representative slide has been submitted for your review.

Diagnosis: Cellular Schwannoma

Differential Diagnosis

• Meningioma

• Smooth muscle tumors

• Schwannoma

• MPNST

• Melanoma

Key Microscopic Features:

• Densely cellular, vaguely fascicular arrangement of cells with obscure cell borders consisting mainly of Antoni A pattern

• Low mitotic index

• Low Ki-67 proliferation index

• Focal arrangement of cells with whorls

• Focal areas of cells with cytoplasmic clearing

• Areas of pigmentation due to hemosiderin

• Focal areas of hyalinization of large vessels

• Resistance of specimen to disaggregation during smearing

Discussion:

Most schwannomas do not recur. However, cellular schwannomas, a subtype consisting of densely cellular Antoni A pattern may recur at rates as high as 50%. Mitosis index and Ki-67 indices do not reliably predict the recurrence. These tumors, despite high local recurrence rates, are not malignant and therefore they should not be overcalled as MPNST. About half of these cases are diagnosed as schwannomas initially and later diagnosed as cellular schwannomas after recurrence.

References:

1. Cellular Schwannoma: A Clinicopathologic, DNA Flow and Proliferation Marker Study of 70 Patients. Casadei GP, Scheithauer BW, Hirose T, Manfrini M, Van Houton C, Wood MB. Cancer. 1995 Mar 1;75(5):1109-19.

2. Pathology of peripheral nerve sheath tumors: diagnostic overview and update on selected diagnostic problems. Rodriguez FJ, Folpe AL, Giannini C, Perry A. Acta Neuropathol. 2012 Mar;123 (3):295-319.

3. Cellular schwannoma. A clinicopathologic study of 57 patients and 58 tumors.

White W, Shiu MH, Rosenblum MK, Erlandson RA, Woodruff JM.

Cancer. 1990 Sep 15;66(6):1266

Case 3: Small Cell Carcinoma of the Hypercalcemic Type of the Ovary.

Zulfiya Ibragimova MD., Jodi Speiser. M.D., Çaðatay Erþahin, M.D., PhD

Clinical history: 27 year-old female presented with abdominal pain and increasing abdominal girth. Paracentesis at that time showed 350 cc of blood tinged fluid. CA-125: 307 U/ml (normal = ................
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