Pathways Case Studies: May 2019

A 57-year-old woman with a history of cholecystectomy presents to the emergency room with sharp epigastric pain penetrating through to her back. She was hospitalized at that time for three days and found to have elevated pancreatic enzymes. Her imaging showed extensive pancreatic calcification, with small popcorn-type distribution throughout the gland, consistent with chronic pancreatitis. Her abdominal MRI showed innumerable pancreatic cysts throughout the pancreas, with the largest measuring at least 2.2 cm at the pancreatic head. No dilatation of the main pancreatic duct (Figure 1). The radiological differential diagnosis was multifocal branch intraductal papillary mucinous neoplasm (IPMN). The patient underwent endoscopic ultrasound fine needle aspiration (EUS/FNA) (Figure 2 A-D). Her pancreatic cyst amylase was 284110 I/U, and CEA was 145.

	Sam Albadri, M.B., Ch.B., M.S. Fellow, Cytopathology Mayo Clinic @Sam_Albadri
	Longwen Chen, M.D., Ph.D. Consultant, Anatomic Pathology Mayo Clinic Associate Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

74-year-old female presented with a painless right parotid mass that had been stable for two years. Imaging showed a (1 cm) hypoechoic, slightly lobulated nodule. The patient underwent FNA aspiration followed by resection of the right superficial parotid gland. Significant clinical history for recent squamous cell carcinoma of the right cheek and remote history of right breast invasive ductal carcinoma.

	Farah Baban, M.B., Ch.B. Resident, Anatomic and Clinical Pathology Mayo Clinic @BabanFarah
	Diva Salomao, M.D. Consultant, Anatomic Pathology Mayo Clinic Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine @DivaRSalomao

A 21-year-old man with a history of germ cell tumor status post orchiectomy, reported as a 7 cm mass; 80% yolk sac and 20% teratomatous, presented with a lesion in his left lung. The wedge resection revealed a 1.3 cm solid mass. The tumor contained a population of mononuclear cells with nuclear pleomorphism, and a population of larger multinucleated cells with smudged chromatin. Immunohistochemistry revealed immunoreactivity to hCG and GATA3 and no immunoreactivity to OCT3/4 and CD30.

	Sara Cook, M.D., Ph.D. Resident, Anatomic and Clinical Pathology Mayo Clinic
	Ruifeng (Ray) Guo, M.D., Ph.D. Senior Associate Consultant, Anatomic Pathology Mayo Clinic Assistant Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine
	Loren Herrera Hernandez, M.D. Consultant, Anatomic Pathology Mayo Clinic Assistant Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

A 23 year old presents to his family care physician with a five-month history of right-sided facial numbness and eyelid twitching. He is a non-smoker and has no previous malignant history. An ultrasound of his face showed a 3-4 cm hypoechoic mass in the parotid. An outside biopsy was positive for a “round blue cell tumor.” Clinically the mass was rapidly enlarging over the course of weeks-months. A CT of the mass is shown.

	Casey Gleue, M.D. Resident, Anatomic and Clinical Pathology Mayo Clinic
	Joaquín García, M.D. Consultant, Anatomic Pathology Mayo Clinic Associate Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

A 33-year-old previously healthy female presented with a painless abdominal lump. CT scan revealed an 8.6 cm homogeneous soft tissue mass centered in the right central mesentery with associated lymphadenopathy involving the mesenteric, retroperitoneal, and para-aortic lymph nodes. CBC showed hemoglobin of 12.6 g/dL, platelets of 304 x 10(9)/L and WBC of 7 x 10(9)/L. Core needle biopsy of the right mesenteric mass was performed. Immunohistochemical stains were negative for keratin, SOX10, CD3, CD10, CD19, CD20, CD30, ALK, BCL2, BCL6, MYC, and MUM1.

	Aishwarya Ravindran, M.B.B.S. Resident, Anatomic and Clinical Pathology Mayo Clinic @aravindranmd
	Karen Rech, M.D. Consultant, Hematopathology Mayo Clinic Assistant Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine

A 40-year-old female with family history of alpha-thalassemia was evaluated for anemia. The gap PCR and multiplex ligation-dependent probe amplification (MLPA) test were performed using this patient’s blood specimen. The results are shown below.

	Guang Yang, B.Med., Ph.D. Resident, Molecular Genetic Pathology Mayo Clinic
	Kandelaria (Ande) Rumilla, M.D. Consultant, Laboratory Genetics and Genomics Mayo Clinic Assistant Professor of Laboratory Medicine and Pathology Mayo Clinic College of Medicine