Douglas P. Rhone

Pathologic Quiz Case

65-year-old white woman presented to her primary care physician with the complaint of right upper quadrant pain. Her medical history was remarkable for hypertension, diabetes mellitus, and asthma. She was evaluated for cholelithiasis, and gallstones were detected. A 6.0-cm right adrenal mass was detected by computed tomographic scan (Figure 1). Evaluation of the chest, abdomen, and pelvis, including computed tomographic scanning and magnetic resonance imaging revealed no other lesions. Determination of urinary cortisol and vanillylmandelic acid levels showed no evidence of a functioning tumor. Cholecystectomy and excision of the right adrenal mass were performed. The gallbladder showed chronic cholecystitis and cholelithiasis. The right adrenalectomy specimen consisted of an 8.0 3 7.5 3 5.5-cm ovoid mass with a focally hemorrhagic surface. The hemorrhagic oval mass formed nearly 90% of the specimen, was fairly well circumscribed, and was surrounded by a rim of flattened adrenal tissue. Cut section revealed a variegated cut surface (Figure 2). Histopathologic examination revealed ovoid nests, papillary fronds, and solid areas of tumor cells, which on occasion formed vascular channels containing red blood cells. The tumor cells were large, round to oval, and markedly atypical with moderately abundant amphophilic cytoplasm and poorly developed cell borders. The nuclei were vesicular, round to oval, and contained prominent eosinophilic nucleoli. Brisk mitotic activity was present, and atypical mitotic figures were identified. Occasional intracytoplasmic lumina contained red blood cells (Figure 3). The tumor infiltrated residual adrenal cortical tissue in small clusters and as single cells. The capsule of the adrenal capsule appeared intact. Immunohistochemical studies showed strong staining for factor VIII‐related antigen (Figure 4), vimentin, and focal positivity for pancytokeratin. Staining for neuron specific enolase and synaptophysin were not detected. What is your diagnosis?

Testicular Natural Killer/T-Cell Lymphoma, Nasal Type, of True Natural Killer-Cell Origin

The majority of primary testicular lymphomas are of B-cell type. Other primary lymphomas are rarely encountered in the testes. Natural killer (NK)/T-cell lymphomas of nasal type are aggressive extranodal lymphomas associated with Epstein-Barr virus infection that are usually encountered in the upper aerodigestive tract. They also occur in the skin, soft tissue, and colon. Primary testicular NK/T-cell lymphomas are rarely reported. We describe the case of a 66-year-old Korean man who presented with right-sided painless testicular enlargement and underwent radical orchiectomy. Histologic examination revealed an angiocentric and angioinvasive infiltrate of medium to large tumor cells with moderately abundant pale pink cytoplasm and folded and indented pleomorphic nuclei. Paraffin immunohistochemical studies showed positivity of the tumor cells for CD45, TIA-1, granzyme B, CD56, and CD3 epsilon. In situ hybridization showed diffuse positivity for Epstein-Barr virus-encoding RNA. The results of gene rearrangement studies for the gamma chain of the T-cell receptor were negative. The results of paraffin immunohistochemical studies for CD20, CD8, CD45RO, beta f1, and ALK-1 were negative. An extensive workup showed no evidence of lymphoma outside the testes. We report a rare case of primary testicular NK/T-cell lymphoma of the nasal type of true NK-cell origin.

Gastric toxoplasmosis in a patient with acquired immunodeficiency syndrome. A case report and review of the literature.

Toxoplasmosis is a common opportunistic pathogen in patients with acquired immunodeficiency syndrome (AIDS). It usually presents with ocular, central nervous system, or pulmonary disease. Gastric toxoplasmosis is uncommon in AIDS patients, especially in the absence of central nervous system manifestations. In the few reported cases, patients have presented with abdominal pain and other digestive complaints that usually are attributed to the more common gastrointestinal manifestations of human immunodeficiency virus infection. We describe a 49-year-old man with AIDS who presented with abdominal pain, diarrhea, dry cough, and systemic symptoms and was diagnosed with toxoplasmosis by a gastric biopsy.

Malignant Sertoli cell tumor of the ovary metastatic to the lung mimicking neuroendocrine carcinoma: Report of a case

A Sertoli cell carcinoma of the ovary with lung metastases mimicking neuroendocrine carcinoma is presented. Lung metastases frequently occur. Primary and secondary tumors may exhibit similar growth patterns and differentiating primary from secondary tumors may be troublesome. This process may be more difficult when metastases occur from a tumor in which metastases are uncommon and morphologically resemble only a small portion of the primary tumor. We report the case of a 52-year-old woman who underwent resection of a 4,550-g Sertoli cell tumor of the ovary. Histologically, in addition to the characteristic tubular pattern of growth, 5% of the tumor consisted of poorly differentiated areas with tumor cells in sheets, a high mitotic rate, and areas of necrosis. Eleven months after this surgery she presented at a different institution with multiple pulmonary nodules. Microscopic examination of a subsequently resected lung nodule showed histologic findings similar to those of the poorly differentiated areas of the ovarian tumor and initial immunohistochemical studies showed positive staining for cytokeratin, neuron-specific enolase, and focal positivity for synaptophysin. Without knowledge of the ovarian tumor the lung lesion was interpreted as large-cell neuroendocrine carcinoma. On review of the clinical history and comparison with the previous surgical material, however, both tumors showed similar light microscopy and immunohistochemical reactivity, and a final diagnosis of metastatic Sertoli cell tumor was made. Immunohistochemical staining for inhibin revealed weak positivity in the poorly differentiated areas of the ovarian tumor but not in the lung metastasis. This is one of the rare reports of ovarian Sertoli cell tumor metastasizing to the lungs and it emphasizes the importance of complete clinical histories, ancillary studies, appropriate sampling, and review of archival material in such unusual cases.

Hepatic and Splenic Phagocytosis of Isophilic and Heterophilic Antigens in Immunized Rats

Summary Hepatic and splenic uptakes of 51Cr-labeled sheep red cells (SRC) were significantly depressed in adult rats which had previously been immunized with heterophilic antigen (HA, boiled homogenate of guinea pig kidney). Uptake of 51Cr-labeled HA was not affected by preimmunization. Administration of HA to newborn rats significantly depressed uptake of 51Cr-SRC, but not of 51Cr-HA, given 10–13 weeks later. Administration of SRC to newborn rats failed to interfere with uptake of 51Cr-SRC or 51Cr-HA later in life. Since these observations parallel the reduced formation of antibodies for SRC in rats preimmunized with HA, the changes in phagocytosis and immune responses may be attributable to imprinting of numerous macrophages with receptors specific for HA. Subsequently introduced SRC may thus be diverted to HA-specific macrophages and be prevented from contact with macrophages better equipped to phagocytose and process this substrate containing both heterophilic and isophilic antigens.