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CASE STUDIES PART 2. Neoplasia. Adenoma. Stalk. Polyp. “Apple Core”.
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CASE STUDIES PART 2 Neoplasia
Adenoma Stalk
“Apple Core” This barium enema with the patient in a lateral position (head toward the right of the image) demonstrates two encircling masses, one in the transverse colon and one in the descending colon. These are typical adenocarcinomas.
Fibroids Leiomyoma (Leiomyosarcoma if malignant)
Case 1 History: • This was an incidental finding in a 15 year old girl that was found at the time of appendectomy. A discreet yellow mass was observed in the small bowel wall and was resected.
Questions: 1. What is the degree of differentiation? 2. What is the malignant counterpart of this lesion?
Case 1: Lipoma Answers: • What is the degree of differentiation? This neoplasm is extremely well-differentiated, as it resembles normal adipose tissue. It is completely benign. In general, the degree of differentiation is helpful in grading a neoplasm. In general, the better differentiated a tumor, the lower grade it is. • What is the malignant counterpart of this lesion? Liposarcoma. Such a neoplasm would most likely be found in deep soft tissues in thigh or retroperitoneum. Lipomas can be found in a variety of locations and are generally small.
@ Case 2 (pg 299 for lecture) History: • A 52 year old woman underwent a hysterectomy because she had irregular menstrual bleeding. At surgery, the uterus appeared nodular (as in kodachrome slide #4 above). In surgical pathology on dissection, the nodules were firm, white, discreet, and arose in the myometrium.
Questions: 1. If multiple tumor masses are present, then why isn't this metastatic? 2. What is the malignant counterpart of this lesion and does it often arise from leiomyoma?
Case 2: Leiomyoma of uterus Answers: • If multiple tumor masses are present, then why isn't this metastatic? This is an example of multicentric origin of a neoplasm within an organ. The benign nature of these neoplasms is confirmed histologically. Each individual tumor is benign. Malignant tumors can also sometimes be multicentric in origin, but in general there is usually a single primary tumor from which metastases originate. • What is the malignant counterpart of this lesion and does it often arise from leiomyoma? Leiomyosarcoma. Such malignant smooth muscle tumors usually arise de novo. Although about one out of every five or six women has a leiomyoma, leiomyosarcomas are rare.
Case 3 History: • A 61 year old farmer began complaining of vague chronic abdominal pain. This was associated with a 20 lb weight loss over several months. Endoscopy revealed an irregular area of shallow ulceration on the lesser curvature of the stomach. This area was biopsied and showed adenocarcinoma. At surgery, exploration of the abdomen revealed an area of diffuse, firm thickening of the stomach wall.
Lesion Lumen
Questions: • Why is the cancer accompanied by weight loss? 2. How has the incidence of stomach cancer changed in the U.S. in this century?
Case 3: Adenocarcinoma of stomach Answers: • Why is the cancer accompanied by weight loss? Malignant neoplasms are often accompanied by weight loss. This may be from loss of appetite (nausea, feelings of abdominal fullness), increased metabolic demand, or by interference with eating or digestion. In general, the greater the weight loss, the worse the prognosis. • How has the incidence of stomach cancer changed in the U.S. in this century? Gastric adenocarcinoma has decreased in incidence. It remains high in Japan.
Case 4 History: • A 73 year old woman from Salt Lake City underwent mammography. Both her mother and a maternal aunt died of breast cancer. The mammogram revealed a poorly defined mass in the left breast. A mastectomy was performed.
Duct Malignant Tumors
No surgery, too late. Causes inflammation. (orange peel on the skin)
Questions: 1. What is the significance of the history of breast cancer in the family? 2. What is the degree of differentiation? 3. What methods are available for diagnosis of the mammographic lesion to determine if mastectomy should be performed?
Case 4: Infiltrating ductal carcinoma of breast Answers: • What is the significance of the history of breast cancer in the family? A maternal family history of breast cancer (mother, aunt, sister) suggests an increased risk of breast cancer for the patient. • What is the degree of differentiation? This neoplasm is moderately differentiated. The neoplastic cells are attempting to make ill-defined ducts. • What methods are available for diagnosis of the mammographic lesion to determine if mastectomy should be performed? Needle aspiration biopsy can be done for cytologic diagnosis. An excisional biopsy will yield more tissue for definitive diagnosis and for hormone receptor assay if malignant.
Case 5 History: • An 82 year old woman was admitted in severe respiratory distress. History revealed that she had undergone mastectomy seven months previously.
Questions: 1. What are typical routes for metastases? How do these routes differ in regard to the primary site and cell of origin? 2. How did the metastases account for the clinical presentation?
Case 5: Metastatic breast carcinoma in lung Answers: • What are typical routes for metastases? How do these routes differ in regard to the primary site and cell of origin? Carcinomas often spread via lymphatics to regional lymph nodes. The primary site will determine which nodes are affected--thus enlarged hilar nodes suggest a lung primary, axillary nodes a breast primary, cervical nodes a head & neck primary, etc. Carcinomas may also spread locally by direct extension, to distant sites via the bloodstream, and by seeding through body cavities. Sarcomas are less likely to use lymphatic spread and more likely to use hematogenous spread. • How did the metastases account for the clinical presentation? The metastases occluded vascular channels in the lung (tumor emboli), leading to an appearance similar to pulmonary embolization. If larger metastatic lesions are present, they can compromise lung function by simply reducing lung capacity or obstructing bronchi.
Case 6 History: • A 38 year old woman had heavy, irregular menstrual bleeding. She was treated with endometrial curretage followed by hysterectomy.
Questions: 1. What is the significance of hyperplasia in this setting? 2. How does hyperplasia differ from neoplasia?
Case 6: Endometrial hyperplasia (Benign) Answers: • What is the significance of hyperplasia in this setting? This could represent a preneoplastic condition. • How does hyperplasia differ from neoplasia? The hyperplasia is potentially reversible, whereas a neoplasm is autonomous growth. Sometimes the distinction is difficult to make on a small biopsy sample or on cytology. The hyperplasia could be "atypical" and show changes similar to that of a neoplasm. Conversely, a neoplasm could be well-differentiated and resemble normal or hyperplastic tissue.
Case 7 History: • A 49 year old male had a 100 pack/year history of smoking. He had a chronic cough, but recently he noted some blood-streaked sputum. A chest x-ray showed a hilar shadow. After clinical work-up, the tumor that was found was not amenable to resection. He died soon after initiation of radiation therapy.
Questions: 1. What caused this cancer? 2. Where would this tumor metasatasize first? 3. What methods are available for diagnosis of this neoplasm?
Case 7: Squamous cell carcinoma of lung Answers: • What caused this cancer? Smoking. • Where would this tumor metasatasize first? Hilar lymph nodes. It could also later spread to the pleura and chest wall locally. Distant metastases could include sites such as the opposite lung, adrenal, bone marrow, and brain. • What methods are available for diagnosis of this neoplasm? Sputum cytology, bronchoalveolar lavage, transbronchial biopsy, open lung biopsy (in increasing order of invasiveness) for histologic diagnosis. Radiographic procedures can be used initially to determine if a mass is present and, if so, where to sample tissue.
Case 8 null History: • This 12 year old male noted pain in the left lower leg, even at night, for several months following a blow to the calf from a soccer ball. A radiograph revealed a mass lesion involving the metaphysis of the distal femur.
