The University of Pittsburgh Medical Center
Department of Pathology
Surgical Pathology Report
SP Number: S97-00000
Hospital Number 000-00-0000
Name: Kirk, James
Date of Birth: 00/00/0000
Report Type: Surgical Pathology Telereport
Patient Status: Consultation
Accession Date: 00/00/97
 Pathologist: Eric Schubert MD
Clinician: Dr McCoy
Referring Pathologist: Dr Quincy
Referring Institution: Central Hospital



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PATIENT HISTORY: The patient is a 65 year old female with a non-enhancing ("cold") nodule of the right lobe of the thyroid, with two enlarged lymph nodes in the right jugular region. The patient also had non- enhancing lesions of the liver.
PRE-OP DIAGNOSIS: Not given.
POST-OP DIAGNOSIS: Not given.
PROCEDURE: Neck mass excision, right thyroidectomy.
kmr
This report includes the special procedure(s) listed below:
ELECTRON MICROSCOPY

Pending special procedure(s) listed below. Updated reports to follow.
ELECTRON MICROSCOPY #2
ADDENDUM #1:
CD21 CD68
Since the original report, tissue has been processed for electron microscopy, as well as immunoperoxidase stains for CD21, CD68 and Actin. These additional studies show the tumor is strongly positive for CD21 with focal positivity for CD68. Electron microscopy studies show primitive type cell junctions but otherwise no other distinguishing diagnostic features. We believe that considering all of the studies, the diagnosis is that of a follicular dendritic cell tumor. This is a recently recognized rare tumor that is known by a few other names (spindle cell neoplasm of lymph nodes of reticulum cell lineage, sarcoma of follicular dendritic cells, among others). It is a tumor arising in the dendritic cells of lymph node follicles. In the studies reported thus far, patients have been treated with a variety of modalities,including chemotherapy,radiation and/or surgery.

References:
1. Weiss L.M., et al. AM J Surg Pathol, 14 (5): 405-414, 1990.
2. Chan J.K.C., Tsang W.Y.W and Ng C.S., AM J Surg Pathol, 18 (5): 517-525, 1994.
3. Chan J.K.C., et al. AM J Surg Pathol, 18 (2): 148-157, 1994.

The final diagnosis now should read:
PARTS 1 AND 2: RIGHT HEMITHYROID AND RIGHT CERVICAL LYMPH NODE, EXCISION -
A. SARCOMA OF FOLLICULAR DENDRITIC CELLS INVOLVING RIGHT HEMITHYROID (1.5 CM.) AND ONE CERVICAL LYMPH NODE.
B. NO EXTRANODAL SPREAD OF TUMOR IS SEEN (See addendum and references).
(1 CD68, 2 CD21 and 1 Actin), Slides were reviewed.
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ELB/kmr/ELB

Pathologist: E. Leon Barnes, M.D.
** Report Electronically Signed Out **
By Pathologist: E. Leon Barnes, M.D.
12/07/95 12:44
FINAL DIAGNOSIS:
PART 1: LYMPH NODE, RIGHT CERVICAL -
A. METASTATIC UNDIFFERENTIATED MALIGNANT NEOPLASM (See Comment).
B. NO EXTRA CAPSULAR EXTENSION SEEN.
PART 2: THYROID, RIGHT THYROIDECTOMY -
A. UNDIFFERENTIATED MALIGNANT NEOPLASM WITH EXTENSIVE VASCULAR INVASION (See Comment).
B. RESECTION MARGIN ARE FREE OF TUMOR.
C. NON SPECIFIC THYROIDITIS.
COMMENT:
Irregular Nodules Storiform Pattern Numerous abnormal mitotic figures
The tumor is growing as irregular nodules incompletely separated by bands of fibrous tissue. The nodules are composed of solid masses of tumor cells with occasional whirling and storiform patterns intermixed with lymphocytes. The tumor cells range from epithelioid to spindle in shape and have modest to abundant amount of pink cytoplasm. Nuclei are large and irregular with clumped chromatin and large prominent nucleoli. Mitoses are abundant and numerous abnormal mitotic figures are identified. Scattered multinucleated tumor giant cells are also present. The results of immunoperoxidase stains of this tumor are non contributory in indicating a line of differentiation.

Electron microscopy studies are under way and the results will be issued in a separate report.

RLP/seg

Pathologist: Robert Peel, M.D.
Resident: Jeffry S Nine, M.D.
** Report Electronically Signed Out **
By Pathologist: Robert Peel, M.D.
11/30/95 16:11

My electronic signature above is attestation that I have personally reviewed the gross specimen(s) and/or glass slides of the submitted material(s) and that the above diagnosis reflects this evaluation.
GROSS DESCRIPTION:
Right Neck Right Thyroid
The specimen is received two parts.

Part 1 is labeled "right neck" and consists of a 3.5 x 2.2 x 2.2 cm. encapsulated, slightly firm mass. The whole specimen is inked and bisected to reveal a bulging cut surface composed of homogeneous white lobulated tissue. Representative sections are frozen. The remaining tissue is totally submitted in cassette 1A and 1B with representative sections submitted in cassettes 1C and 1D.

Part 2 is labeled "right thyroid" and consists of a 5.5 x 2.5 x 1.5 cm. right thyroid lobe with a smooth outer surface. Cut section reveals a well demarcated, partially circumscribed, tan- white homogeneous and lobulated tumor in the superior pole, 1.5 cm. This tumor has an almost identical gross appearance to the lymph node or the specimen in part 1. A frozen section is done. The remaining tissue is totally submitted in cassette 2A with representative sections submitted in cassettes 2B, 2C and 2D. (Parts 1 and 2), Gross photographs are taken, the specimen is frozen in bulk and in OCT, and tissue is saved in Karnovsky's fixative for EM examination.

kmr
JSN/kmr

INTRAOPERATIVE CONSULTATION:

1A: RIGHT NECK (Frozen section) -
A. DEFER.
B. RULE OUT LYMPHOMA VS. ANAPLASTIC CARCINOMA.
(J.Nine/L.Barnes)
1A: RIGHT THYROID (Frozen section) -
A. DEFER.
B. RULE OUT LYMPHOMA VS. ANAPLASTIC CARCINOMA.
(J.Nine/L.Barnes)
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E. Leon Barnes, M.D.
Jeffrey S. Nine, M.D.

MICROSCOPIC:
Vimentin S-100 AE1 3 (cytokeratin) LCA CD68
(14 HE, Vimentin, S-100, Synaptophysin, Chromogranin, Neurofilament, NSE (Neuro specific enolase), Ewing Stain, AE1 3, (cytokeratin), Cam 5.2 (low molecular weight keratin), Thyroglobulin, Calcitonin, CEA (carcinoembryonic antigen) Leukocyte common antigen (LCA), L26 (B-cells), CD3 (T-cells) Ber H2 (Ki-1), Eber, Epithelia membrane antigen (EMA), Leu M1) Slides reviewed.

The results of these stains are as follows:

Stain Result
Vimentin Positive
S-100 Negative
Synaptophysin Focal positive
Chromogranin Negative
Neurofilament Negative
NSE (Neuro specific enolase) Positive
Ewing Stain Negative
AE1 3 (cytokeratin) Negative
Cam 5.2 (low molecular weight keratin) Negative
Thyroglobulin Negative
Calcitonin Negative
CEA (carcinoembryonic antigen) Negative
Leukocyte common antigen (LCA) Negative
L26 (B-cells) Negative
CD3 (T-cells) Negative
Ber H2 (Ki-1) Negative
CD68 Negative
Eber Negative
Epithelia membrane antigen (EMA) Negative
Leu M1 Focal positive
seg
HISTO TISSUE SUMMARY:
Part Block Sect.Site Stains/Proceedures
1 4 - FR
2 8 - RHHEx18
3 1 -
ELECTRON MICROSCOPY
Internal Number: EM95-334

INTERPRETATION: RIGHT NECK, SOFT TISSUE, EXCISION -
POORLY DIFFERENTIATED CARCINOMA (See comment).
Comment:
Electron microscopic examination reveals cells with numerous interdigitating cytoplasmic processes and occasional intercellular junctions (desmosomes). The amorphous intercellular material could represent submicroscopic amounts of thyroglobulin; immunoperoxidase correlation with this is suggested. In addition, the investigation of this neoplasm with alternate cytokeratin such as CAM 5.2 or AE1 alone are suggested to evaluate the immunohistochemical characteristics of this neoplasm.
mz
ELB/elb

Pathologist: E. Leon Barnes, M.D.
** Special Procedure Report Electronically Signed Out **
By Pathologist: E. Leon Barnes, M.D.
12/11/95 1337

RESULTS:
Low Power Desmosomes Cellular Processes
Tissue was received in Karnovsky's fixative labeled "S95-20149, Right Neck, soft tissue". Additional tissue is available if needed.

Examination of the Toluidine blue stained tissue reveals sheets of large pleomorphic cells with a high nuclear to cytoplasmic ratio. A second population of small lymphocytic cells is admixed with these larger cells. Fine capillaries are interlaced within the section. These findings are similar to those seen on the HE material.
Ultrastructural examination reveals large cells with increased heterochromatin and prominent nucleoli, admixed with normal- appearing lymphocytes. These large cells display occasional poor to well-formed desmosomes; no junctional complexes are seen, however. Numerous cellular processes extend from and interdigitate throughout the sections. Intracytoplasmic filaments are not appreciated. A dark granular material is present focally between some of the large cells.
mz

Consulting Pathologist(s):

Robert Peel, M.D.
Steven H. Swerdlow, M.D.

** END OF REPORT ** KIRK, JAMES S97-00000