Abdominal CT With Contrast
Study Result
Impression
The lower posterior mediastinal to retroperitoneal mass with dimensions as outlined above. Lymphoma is suspected.
Acute LEFT first rib fracture at the costochondral junction.
WS: 129674-RAD
Signed By: Ranji Samaraweera, MD on 4/5/2017 3:56 PM
Narrative
CT CHEST ABDOMEN PELVIS W CONTRAST
HISTORY: Neoplasm of uncertain behavior, unspecified
Abn findings on diagnostic imaging of body structures
retroperitoneal mass
COMPARISON: None
TECHNIQUE: CT CHEST ABDOMEN PELVIS W CONTRAST Sagittal, axial, and coronal scans reconstructions were generate from the acquired images and reviewed.
CONTRAST: IOPAMIDOL 76 % IV SOLN 80 mL
All CT Scans at this facility use dose modulation, iterative reconstruction, and/or weight based dosing when appropriate to reduce radiation dose to as low as reasonably achievable.
FINDINGS:
Scans through the chest demonstrate the lungs are clear. The airways are widely patent the hila and mediastinal soft tissues appear unremarkable. There is no evidence of mass or adenopathy. The heart is not enlarged. There is no pleural or
pericardial effusion. No evidence of a pneumothorax. There is a fracture at the LEFT first rib costal chondral junction. This appears acute. There are no other fractures evident. There are no osteolytic or destructive changes.
Within the abdomen, the liver, spleen, the pancreas and the adrenal glands appear unremarkable. The kidneys demonstrate no discrete focal abnormality. No stones. No hydronephrosis or hydroureter.
There is a prominent retroperitoneal soft tissue mass which extends from the retrocrural region of the diaphragm on the RIGHT into the abdominal retroperitoneum also situated to the RIGHT of midline but between the aorta and the cava. The upper portion
of this lesion appears more soft tissue while the lower portion appears more cystic in density but please note Hounsfield unit measurements still suggest this is more of a solid lesion. Given the retroperitoneal location and the extension from the
posterior inferior mediastinum into the retroperitoneum, the finding is concerning for lymphoma. There is a LEFT para-aortic soft tissue component also noted.
The craniocaudal extent of the retrocrural to retroperitoneal lesion measures 16.3 cm. The anterior posterior extent of the bulkiest component measures 5.9 cm within the midabdomen. The transverse component of the bulkiness lesion measures 6.5 cm the
LEFT para-aortic component measures 2.4 cm AP by 1.9 cm transverse by 2.9 cm craniocaudal.
The spleen measures 12 cm, caudal 6 cm transverse and 12 cm AP.
The small and large bowel do not appear distended or dilated. There is no evidence of mesenteric adenopathy.
Intrapelvic soft tissues appear unremarkable is no mass or adenopathy free or loculated fluid. The osseous structures appear unremarkable through the abdomen and pelvis.
Component Results
There is no component information for this result.
General Information
Collected:
04/05/2017 3:26 PM
Scrotal Ultrasound
Study Result
Impression
- Abnormal appearance of the RIGHT testicle as described above including inhomogeneity and marked microlithiasis. No discrete measurable mass is identified.
2. Moderate sized LEFT varicocele.
3. Trace microlithiasis on the LEFT. The LEFT testicle otherwise appears normal.
4. Small bilateral epididymal head cysts.WS: 129672-RAD
Signed By: Jerome Cordes, MD on 4/14/2017 10:52 AM
Narrative
US SCROTUM W LTD DOPPLER PANEL
HISTORY: RIGHT testicular pain. Has retroperitoneal mass with biopsy showing seminoma.
COMPARISON: None
TECHNIQUE: High resolution gray scale scrotal ultrasound with spectral and color Doppler.
FINDINGS:
Right
Testicle: The RIGHT testicle is diffusely inhomogeneous with marked microlithiasis present diffusely as well. No discrete measurable masses seen although there is definite nodularity to the RIGHT testicle.
Epididymis: 8 mm simple cyst of the RIGHT epididymal head noted.
Scrotal Sac: No hydrocele. No varicocele.
Doppler: Normal.
Left
Testicle: Normal in size and echotexture. There are a few microliths present.
Epididymis: 4 mm simple cyst of the epididymal head noted.
Scrotal Sac: No hydrocele. There is prominence of the LEFT pampiniform plexus which in cord just on Valsalva maneuver up to 5 mm compatible with a moderate size varicocele.
Doppler: Normal.
Measurements:
Right testicle: 4.6 x 2.2 x 2.8 cm
Left testicle: 3.7 x 1.9 x 2.3 cm
Lymph Node Biopsy
Lymph Node Biopsy Pathology
Clinical Information
Diagnosis/PreOp: Retroperitoneal mass
PostOp: None given
Surgical Procedure: Retroperitoneal lymph node/mass bx
Source
Lymph node-biopsy, retroperitoneal mass
Diagnosis
RETROPERITONEAL MASS BIOPSY
– MORPHOLOGIC FEATURES AND STAINING PATTERN CONSISTENT WITH
SEMINOMA (SEE MICROSCOPIC DESCRIPTION).
(mcf[mars])
Comment
The case was also evaluated by Rashi Singhal, M.D., who agrees with the
interpretation. Dr. Kosisocki Obinwanne was informed of the possibility
of germ cell tumor on 4/11/17 at 12:52H. He mentioned that the patient
has testicular pain but no apparent swelling.
Microscopic
The specimen consists of cores of tissue showing large plasmacytoid
cells on the lymphoid background. Because of the possibility of
lymphoma, flow cytometry and immunostains for lymphoma were performed.
The stains were CD20, CD3, CD5, CD10, CD30, CD23, BCL2, BCL6, MUM-1,
cyclin D1. These stains showed that the large cells were negative and
the background was a mixture of B-cells and T-cells. Cytokeratin CAM5.2
was also performed and showed that many of the large cells were
positive. The morphology also suggests a germ cell tumor, such as
seminoma. Additional stains were performed and the tumor cells were
positive for CD10, PLAP, CD117. Pankeratin AE1/AE3 was negative.
FLOW CYTOMETRY RESULTS:
Gated population: Lymphocytes % of nucleated cells: 58.7
MARKERS % POSITIVE
HLA-DR (total) 28
HLA-DR activated T-cells 5
CD2 76
CD3 70
CD5 70
CD7 71
CD4 48
CD8 17
CD4/CD8 ratio 2.8
CD19 23
CD5+CD19 (dual) <1
CD20 22
CD22 22
CD23 5
FMC7 14
CD10+CD19 (dual) <1
CD34 <1
CD45 100
Kappa+CD19 sIg (dual) 12.3
Lambda+CD19 sIg (dual) 7.2
Kappa/lambda ratio (sIg) 1.7:1
CD13 <1
CD14 <1
CD33 <1
Analyte Specific Reagents (ASR): Antibodies used for flow cytometry
were developed and their performance characteristics determined by
Sparrow Hospital. They have not been cleared or approved by the Food
and Drug Administration. FDA does not require these antibodies to go
through premarket FDA review. This test is used for clinical purposes.
It should not be regarded as investigational or for research. This
laboratory is certified under the Clinical Laboratory Improvement
Amendments of 1988 (CLIA) as qualified to perform high complexity
clinical laboratory testing.
Gross
Received in formalin labeled “retroperitoneal mass” are multiple cores
of gray to red-brown tissue that range from 0.1 up to 1.5 cm long.
Inked and entirely submitted as A1. Also received with the specimen is
a vial of flow media labeled “retroperitoneal lymph node biopsy mass”
and contains multiple pink tissue fragments. This specimen is submitted
for flow cytometry. FOP/jkw 04-07-2017
Maria B. Costa-Fox M.D.
Pathologist, (Electronic Signature)
(Case signed 04 12 2017)
Rashi L. Singhal M.D. M.P.H.
Pathologist, (Electronic Signature)
(Case Reviewed 04 12 2017)
Case signout location:
SPARROW LAB (MAIN)
1215 E. Michigan Ave.
Lansing, MI 48912
I (we), the signing pathologist(s), have personally microscopically
examined/interpreted any slides prepared on this case.
Antibodies Utilized
CD-3 (2GV6, VENTANA)
CYCLIN D-1 (SP4, VENTANA)
PLAP (PL8-F6, BIOGENEX)
BCL-2 (124, DAKO)
CD-20 (L26, DAKO)
CAM 5.2 (CAM5.2, BECTON DICKINSON)
CD-5 (SP19, VENTANA)
CD-10 (56C6, VENTANA)
MUM-1 (MUM1p, DAKO)
CD-117 (c-kit, DAKO)
CD-30 (Ber-H2, VENTANA)
PANCYTOKERATIN (AE1/AE3, DAKO)
BCL-6 (PG-B6p, DAKO)
CPT codes
Code CPT Count
000TR 801 1
88184 1781 1
88185 1804 19
88189 801 1
88341 1782 14
88342 786 1
Testicle Pathology
*****AMENDED REPORT*****
Please see end of report for amendment.
Clinical Information
Diagnosis/PreOp: Testicular mass
PostOp: Same
Surgical Procedure: Right radical orchiectomy
Source
Testis, right testicle
Diagnosis
RIGHT TESTIS, RADICAL ORCHIECTOMY
– FOCAL GERM CELL NEOPLASIA IN SITU.
– FIBROTIC SCAR CONSISTENT WITH REGRESSED GERM CELL TUMOR.
– NO INVASIVE GERM CELL TUMOR IDENTIFIED.
(jpj[mars])
Comment
This case has been seen by multiple members of the Department, who agree
with the findings and the absence of neoplasm. After reviewing the
original sections, five additional cassettes were submitted in an effort
to see if any neoplasm could be identified. Dr. Rizar notified of the
diagnosis on 2MAY17. This case with the previous positive biopsy will be
sent to University of Michigan Pathology Department for consultation.
Microscopic
The submitted sections from the right radical orchiectomy demonstrate a
testis which is more than 90% replaced with fibrous tissue. Small
remaining tubules are present which are sclerotic. Occasional tubules
contain germ cells. There are diffuse Leydig cell nests present within
the specimen. Previous surgical (SHS2017-11578) is reviewed and there
are no cells present which have the same histologic appearance within
this testis.
Gross
Received in formalin labeled “right testicle” is a right testicle with
attached spermatic cord. The testicle and spermatic cord are partially
capsulated in a thin translucent tunica vaginalis. The spermatic cord
measures 6.5 cm in length and is up to 2.0 cm in greatest diameter. The
testicle measures 5.5 x 3.5 x 2.2 cm and with attached spermatic cord
weighs 49 grams. The spermatic cord resection margin will be marked
with blue ink. Sections through the spermatic cord reveal yellow-tan
lobulated cut surfaces with vascular structures. No masses are
identified grossly. There is a large fatty area at the junction with
the spermatic cord and the testicle. The tunica vaginalis is adherent
but strips easily from the underlying albuginea. The tunica albuginea
is pale gray and has a vascular pattern. Serial sections through the
testicle reveal predominately firm, smooth, pale gray cut surfaces.
There is a thin rim of tan testicular parenchyma in the periphery. The
pale gray cut surfaces involve an estimated 85 to 90% of the total
volume. No hemorrhagic areas are identified grossly. The pale gray cut
surfaces do not appear to involve the epididymis or spermatic cord.
Representative sections are submitted as follows: spermatic cord
resection margin – A1; remainder sections of spermatic cord – A2, A3;
sections of testicle – A4-A8. MDS/mrk 4/28/2017
John Paul Jones M.D.
Pathologist, (Electronic Signature)
(Case signed 05 02 2017)
Case signout location:
SPARROW LAB (S. CEDAR)
2508 S. Cedar
Lansing, MI 48910
I (we), the signing pathologist(s), have personally microscopically
examined/interpreted any slides prepared on this case.
CPT codes
Code CPT Count
000TR 801 1
88305 4829 1
*****AMENDED REPORT*****
This report is amended at the request of Dr. Jones to reflect a
correction in the diagnosis. The diagnosis is amended after
consultation with the University of Michigan (OC-17-10176) demonstrated
focal germ cell neoplasia in situ. They performed an additional
immunoperoxidase stain for OCT-4 which was positive. The diagnosis is
changed to reflect their impression. In their consultation they state
that regression of germ cell neoplasms are a known phenomena and
residual invasive neoplasm is not identified. The report originally
stated “Negative for neoplasm. Fibrosis consistent with cryptorchid
testis. The correct diagnosis should be focal germ cell neoplasia in
situ and fibrosis consistent with regressed germ cell tumor.
Case originally signed out on 2MAY17 by JPJ.
John Paul Jones M.D.
Pathologist, (Electronic Signature)
(Amended Report Signed 05 10 2017)