Normal Lab Values

Week 17: Endocrine and GI Pathology

Suggested readings from
Robbins 8th ed.
Endocrine System: pp. 1097-1164

Pancreas: 891-904

Inflammatory and Neoplastic GI Disease: pp. 763-832

Cases for Week 17

Review Items for Week 17: Endocrine System

Review Items for Week 17: Pancreas

Review Items for Week 17: Gastrointestinal System

 

Pathology Case Descriptions

CASE NUMBER 429
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Clinical History: A 50-year-old female had a slowly growing mass in the anterior cervical area for two years. Shortly before admission she developed hoarseness and difficulty swallowing. No thyrotoxic manifestations were noted. A subtotal thyroidectomy was performed.

Image Gallery:

(Summary of Gross Findings - click here)
The thyroid was nodular and weighed 250 grams. The capsule was intact. The cut surface revealed large and small honeycombed structures filled with yellow-brown colloid material. Focal hemorrhages and fibrosis were present in the nodules.
(Summary of Microscopic Findings - click here)
The nodules consist of small and large follicles up to 3 mm in diameter. The epithelium is low cuboidal, and the colloid is rich. In some sections there is scalloping at the periphery of the colloid. There is fibrosis as well as focal recent and old hemorrhages. A small amount of atrophic, compressed thyroid tissue may be seen in some sections.
(Review Normal Histology - click here)
Norm No. 5 Thyroid
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Thyroid tissue consists of variably-sized, colloid-filled follicles.  The colloid is eosinophilic and homogeneous. The glandular thyroid cells are cuboidal. The capsule is intact.

 

What is the MOST LIKELY diagnosis?

ANSWER


199-1. The above tumor is:

  1. a benign thyroid neoplasm with multiple nodules.
  2. due to repeated episodes of thyroid hyperplasia and involution.
  3. always associated with a euthyroid state.
  4. always polyclonal.
  5. always cold on a radioisotope scan.

ANSWER


199-2. Which of the following statement about a multinodular goiter is FALSE?

  1. Enlargement may be asymmetrical and compress the trachea
  2. May grow in a retrosternal fashion
  3. May present as a solitary nodule
  4. Hemorrhage, cystic change, fibrosis and calcification may be seen
  5. Multinodular goiter is also associated with a hypofunctioning thyroid

ANSWER

 

 

 

 

CASE NUMBER 264
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Clinical History: A 38-year-old white female complained of a mass in the neck of several months duration. At the time of examination the right lobe of the thyroid was enlarged and somewhat nodular. The opposite lobe was questionably enlarged. She had no symptoms of hypothyroidism or hyperthyroidism.

Image Gallery:

(Summary of Gross Findings - click here)
At the time of surgery the entire thyroid was enlarged, with an estimated weight of 60 grams. The tissue was pale and lobulated. A subtotal thyroidectomy was performed. The excised tissue weighed 30 grams.
(Summary of Microscopic Findings - click here)
The architecture of the gland is destroyed. A few acini are present. These vary in size. There is abundant lymphoid tissue in which are germinal centers. There are collections of rather large cells which do not form acini.
(Review Normal Histology - click here)
Norm No. 5 Thyroid
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Thyroid tissue consists of variably-sized, colloid-filled follicles.  The colloid is eosinophilic and homogeneous. The glandular thyroid cells are cuboidal. The capsule is intact.

 

264-1. These images depict an example of:

  1. Riedel’s thyroiditis
  2. DeQuervain thyroiditis
  3. Subacute lymphocytic thyroiditis
  4. Hashimoto’s thyroiditis
  5. Fungal thyroiditis

ANSWER

 

 

264-2. Which of the following is NOT a typical feature of this disease?

  1. Granulomatous inflammation
  2. Lymphoid follicles with prominent germinal centers
  3. Thyroid epithelial cells feature abundant, eosinophilic cytoplasm (oncocytic change)
  4. Destruction of thyroid acini
  5. ALL of the above

ANSWER

 

 

264-3. Concerning Hashimoto's thyroiditis:

  1. Granulomatous inflammation is a characteristic feature
  2. May present with either thyrotoxicosis and hypothyroidism
  3. Is distinguished from subacute lymphocytic thyroiditis by the paucity of lymphocytes
  4. Idiopathic retroperitoneal fibrosis is a common complication

ANSWER

 

 

264-4. With regard to thyroiditis:

  1. The epithelial cells in Hashimoto thyroiditis may display ample, eosinophilic cytoplasm (Hurthle cells)
  2. The fibrous variant of Hashimoto thyroiditis features keloid-like collagenous bundles that extend outside the thyroid gland
  3. The principal manifestation of subacute lymphocytic (painless) thyroiditis is hypothyroidism
  4. Riedel’s thyroiditis has a viral etiology and is associated with retroperitoneal fibrosis
  5. DeQuervain’s thyroiditis is an autoimmune disease

ANSWER

 

 

 

CASE NUMBER 430
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Clinical History: A 33-year-old woman presented with a nodule in her neck.

Image Gallery:

(Summary of Gross Findings - click here)
Sectioning through a lobe of excised thyroid gland reveals a papillary carcinoma. This neoplasm can be multifocal, as seen here, because of the propensity of this neoplasm to invade lymphatics within thyroid, and lymph node metastases are common. The larger mass shown here is cystic and contains papillary excresences.
(Summary of Microscopic Findings - click here)
The tumor is composed of papillae covered by closely packed cells with bland, sometimes optically-clear ("Orphan-Annie eye") nuclei. Nuclear grooves are also present. A few round purplish calcifications, termed psammoma bodies, are also seen.
(Review Normal Histology - click here)
Norm No. 5 Thyroid
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Thyroid tissue consists of variably-sized, colloid-filled follicles.  The colloid is eosinophilic and homogeneous. The glandular thyroid cells are cuboidal. The capsule is intact.

 

430-1. What is the histological diagnosis of this thyroid neoplasm?

  1. Papillary thyroid carcinoma
  2. Medullary thyroid carcinoma
  3. Follicular thyroid carcinoma
  4. Anaplastic thyroid carcinoma
  5. Oncocytic thyroid carcinoma

ANSWER

 

 

430-2. Which of the following is a characteristic histological feature of this neoplasm?

  1. A heavy lymphocytic infiltrate
  2. Nuclear grooves and pseudoinclusions
  3. Amyloid deposition
  4. Capsular and vascular invasion
  5. Large pleomorphic giant cells

ANSWER

 

 

 

CASE NUMBER 79
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Clinical History: A 45-year-old male entered the hospital two days prior to death for evaluation of hyperglycemia and elevated serum cortisol. He died unexpectedly.  

Image Gallery:

(Summary of Gross Findings - click here)
The combined weight of the adrenals was 19 grams. There were several yellow cortical nodules up to 0.6 cm in diameter.
(Summary of Microscopic Findings - click here)
Within the nodule of tissue at one end of the section, the cells are mostly in a fascicular arrangement. They are vacuolated and histologically appear identical to normal cortical cells.
(Review Normal Histology - click here)
Norm No. 11 Adrenal gland
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Adrenal tissue is composed of a central medulla and outer cortex. The medulla contains large polygonal neuroendocrine cells. The cortex contains cells with foamy cytoplasm. There is no evidence of hemorrhage or necrosis.

 

79-1. What is the MOST LIKELY diagnosis?

  1. Adrenal cortical carcinoma
  2. Adrenal cortical adenoma
  3. Pheochromocytoma
  4. Metastatic carcinoma
  5. Adrenal myelolipoma

ANSWER

 

79-2. Which of the following statements is TRUE?

  1. If this is a solitary tumour, the cortex adjacent to it is most likely normal in thickness
  2. The cut surface is usually brown due to the presence of melanin
  3. A large tumor (>20 cm in diameter) with areas of hemorrhage and necrosis may indicate malignant change
  4. Nuclear pleomorphism is pathognomonic of malignancy
  5. Such tumors are always hormonally functional

ANSWER

 

79-3. A female infant was referred to the neonatologist with signs of virilization. The doctor ordered a panel of tests to assess adrenal function. He/she is MOST concerned about:

  1. Adrenal cortical adenoma
  2. Adrenal cortical carcinoma
  3. Pheochromocytoma
  4. Congenital adrenal hyperplasia
  5. Waterhouse-Friderichsen syndrome

ANSWER

 

 

CASE NUMBER 427
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Clinical History: A 78-year-old male was admitted with headache and bitemporal hemianopsia of several years duration. No endocrine disturbances were noted. He expired shortly after admission due to pneumonia.

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(Summary of Gross Findings - click here)
The pituitary gland, weighing 3 gms and measuring 2 cms in greatest diameter, contained a large pink-gray soft tumor mass in the anterior lobe. The optic chiasm was slightly atrophic due to the compression of the tumor.
(Summary of Microscopic Findings - click here)
The tumor occupies nearly the entire anterior lobe, so that only a thin rim of normal hypophyseal tissue is present in the subcapsular area. The tumor is composed of uniform cells arranged in a trabecular or sinusoidal pattern. The stroma is highly vascular. Some of the tumor cells contain fine eosinophilic granules, but most of them are chromophobes with special stains.
(Review Normal Histology - click here)
Norm No. 14 Pituitary gland
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The pituitary is an endocrine gland with neurohypophysis and adenohypophysis. The neurohypophysis is composed of spindle cells that are derived from neural crest. These are neurosecretory cells. The adenohypophysis is an endocrine gland which is composed of three histological cell types, acidophils, basophils and chromophobes. The staining properties vary with the hormonal product. For example, growth hormone secreting cells are acidophils.

 

427-1. This is a benign neoplasm that is thought to have arisen from the endocrine cells of the pituitary gland. Which of the following is the BEST histological diagnosis?

  1. Pituitary carcinoma
  2. Pituitary adenoma
  3. Pituitary hyperplasia
  4. Pituitary choristoma
  5. Pituitary hamartoma

ANSWER

427-2. Pituitary adenoma:

  1. May be separated from hyperplasia by the lack of reticulin network and a monomorphic appearance
  2. May cause Cushing’s disease due to hyperfunctioning gonadotrophs
  3. Is classified based on size and location
  4. Typically presents with homonymous hemianopsia
  5. Is a component of tuberous sclerosis

ANSWER

 

 

CASE NUMBER 93
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Clinical History: A 50-year-old female had recurrent bouts of severe abdominal pain accompanied by elevated serum amylase. After one of these episodes, she developed refractory shock, peritonitis and expired.

Image Gallery:

(Summary of Gross Findings - click here)
Hemorrhage is seen in the head of the pancreas. The stomach is reflected superiorly and the spleen can be seen at the far upper right. The pancreas is swollen and does not show the typical tan, lobulated architecture. Instead, it has areas of hemorrhagic necrosis that appear as black.
(Summary of Microscopic Findings - click here)
Several areas of fat necrosis with adjacent neutrophil infiltrate are seen, evidence of acute pancreatitis. In addition, some lobules of the pancreas show fibrosis and loss acini, evidence of chronic pancreatitis. In these areas, islets of Langerhans appear larger and more abundant. This is partly because they are resistant to injury and persist when acini are destroyed and partly because they undergo reactive hyperplasia.
(Review Normal Histology - click here)
Norm No. 7 Pancreas
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The pancreas is comprised of glandular tissue with endocrine and exocrine function. The exocrine pancreas contains lobular arrays of acini. The acinar secretions of the exocrine pancreas are collected by the pancreatic ducts. The ducts are surrounded by a small amount of connective tissue without inflammation or fibrosis (scarring).The endocrine pancreas resides in the islets which are regularly arranged and present within the pancreatic lobules.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

93-1. Which of the following statements about this disease are TRUE?

  1. Caused by repeated episodes of acute pancreatitis
  2. Causes progressive inflammation with fibrosis and calcification of exocrine pancreas.
  3. Involves the endocrine pancreas late in the disease and may cause diabetes mellitus.
  4. Results in pancreatic insufficiency
  5. ALL of the above
  6. NONE of the above

ANSWER

 

 

 

CASE NUMBER 189
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Clinical History: An 80-year-old white male had a three week history of chalky and greasy stools, a 20 pound weight loss, and a progressive obstructive jaundice. A cholangiogram revealed an obstruction in the common bile duct.

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(Summary of Gross Findings - click here)
The head of the pancreas was enlarged with yellow-gray firm tissue, in which no normal lobular structures were seen. About 4 cm proximal to the ampulla there was a stenosis of the common bile duct. Proximal to this stenosis the bile ducts were markedly dilated with bile. The peripancreatic lymph nodes and the celiac axis were gray and firm with metastastic tumor.
(Summary of Microscopic Findings - click here)
The tumor is composed of duct-like structures, which are irregularly arranged and infiltrate into the dense connective stroma and perivascular or perineural lymphatics. Occasionally both ducts and individual tumor cells contain mucin. There is a small amount of pancreatic tissue which shows marked atrophy and fibrosis. The small ducts are distended and may show focal squamous metaplasia of the epithelium in some sections.
(Review Normal Histology - click here)
Norm No. 7 Pancreas
[ImageScope] [WebScope]

The pancreas is comprised of glandular tissue with endocrine and exocrine function. The exocrine pancreas contains lobular arrays of acini. The acinar secretions of the exocrine pancreas are collected by the pancreatic ducts. The ducts are surrounded by a small amount of connective tissue without inflammation or fibrosis (scarring).The endocrine pancreas resides in the islets which are regularly arranged and present within the pancreatic lobules.

 

189-1. Which is the MOST LIKELY diagnosis of this pancreatic tumor?

  1. Pancreatic endocrine neoplasm
  2. Intraductal papilloma
  3. Pseudocyst
  4. Adenocarcinoma
  5. Adenoma

ANSWER

 

 

189-2. Which of the following features in this tumor are important in the histological diagnosis?

  1. Tubule formation
  2. Desmoplastic stromal response
  3. Infiltrative pattern of invasion
  4. ALL of the above
  5. NONE of the above

ANSWER

 

 

189-3. In MOST patients, this particular type of neoplasm arises from the:

  1. Ampulla of Vater
  2. Islets of Langerhans
  3. Pancreatic duct
  4. Pancreatic acini

ANSWER

 

 

189-4. Which of familial syndrome is associated with HIGHEST RISK of this particular type of neoplasm?

  1. Hereditary pancreatitis
  2. Peutz-Jeghers
  3. Familial adenomatous polyposis
  4. Familial atypical multiple mole melanoma

ANSWER

 

 

189-5. The likelihood that this tumor is surgically resectable at the time of diagnosis is:

  1. less than 20%
  2. 30%
  3. 50%
  4. 70%
  5. 90%

ANSWER

 

 

CASE NUMBER 166
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Clinical History: A 43-year-old white female had a four-month history of intermittent bloody stools. Sigmoidoscopy revealed pedunculated polyps 15 cm above the sphincter. She had a family history of colon cancer and the colon was removed prophylactically.

Image Gallery:

(Summary of Gross Findings - click here)
The resected tissue contained several polps. The largest polyp was 1.5 cm in diameter. The stalk was 2 cm in length. The base of the stalk and the adjacent mucosa showed no induration.
(Summary of Microscopic Findings - click here)
The exophytic structure of the polyp can be seen with the naked eye. There is a short stalk lined by normal colon mucosa with blood vessels in the submucosa. The finger-like villi of the polyp are lined by adenomatous mucosa, the hallmark of a neoplastic polyp. Compared to the nearby normal mucosa, the nuclei are elongated, hyperchromatic and stratified. There is increased nuclear to cytoplasmic ratio and decreased cytoplasmic mucin.
(Review Normal Histology - click here)
Norm No. 27 Colon
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The colon is lined by glandular epithelium with numerous mucin secreting goblet cells. The epithelium is infolded into straight tubular glands of uniform diameter to increase the surface area available for secretion and absorption.

 

166-1. This is an example of a:

  1. hyperplastic polyp.
  2. Adenomatous polyp.
  3. juvenile polyp.
  4. hamartomatous polyp.
  5. inflammatory polyp.

ANSWER

 

 

166-2. The polyp is lined by epithelium that features stratified hyperchromatic nuclei, increased nuclear-cytoplasmic ratio and reduced cytoplasmic mucin. This appearance of the lining epithelium is BEST described as:

  1. normal.
  2. metaplasia.
  3. dysplasia.
  4. hyperplastic.
  5. hamartomatous.

ANSWER

 

 

166-3. This lesion is best characterized as:

  1. tubular adenoma.
  2. tubulovillous adenoma.
  3. villous adenoma.
  4. hyperplastic polyp.

ANSWER

 

 

166-4. The HIGHEST RISK for colon carcinoma is seen in:

  1. tubular adenoma.
  2. tubulovillous adenoma.
  3. villous adenoma.
  4. hyperplastic polyp.

ANSWER

 

 

 

CASE NUMBER 129
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Clinical History: A 70-year-old white male had an insidious onset of dysphagia of six months duration. X-ray revealed a filling defect and stenosis in the lower esophagus. An esophageal resection was performed.

Image Gallery:

(Summary of Gross Findings - click here)
The resected esophagus contained a firm, raised, pink-gray, friable and necrotic 3.5 x 4.5 cm tumor mass, completely encircling the esophagus and producing a marked stenosis.
(Summary of Microscopic Findings - click here)
At one end of the section the squamous epithelium of the esophagus shows marked atypia, pleomorphism and loss of polarity, but no submucosal invasion. These changes represent carcinoma in situ. By following the mucosal lining, one comes upon an area where the cords and nests of poorly differentiated squamous cells are seen to invade the mucosa and submucosa reaching the muscular layer. At one margin of the section the tumor cells are better differentiated with production of keratin and formation of so-called epithelial pearls. Associated with the tumor are marked fibrous proliferation and intense chronic inflammatory infiltration in the stroma. The tumor invades into, but not through the muscularis propria.
(Review Normal Histology - click here)
Slide UCSF 226 (esophagus, H&E) WebScope ImageScope
Slide UMich 126 40x (trachea & esophagus, H&E) WebScope ImageScope
Slide UMich 153 20x (esophagus, H&E) WebScope ImageScope
Slide UMich 155 40x (gastro-esophageal junct, H&E) WebScope ImageScope

For the purpose of histological descriptions, the esophagus is subdivided into upper (entirely skeletal muscle in the muscularis externa), middle (mixed smooth and skeletal muscle) and lower (entirely smooth muscle) portions. Slide UCSF 226 is from the upper 1/3; slides 126 and 153 are from the middle 1/3; and slide 155 is from the lower 1/3 (at the esophageal-cardiac junction). The esophageal epithelium [example] is the non-keratinized stratified squamous type and is supported by a connective tissue lamina propria. Note the presence of isolated lymphoid nodules [example] and scattered leukocytes in the lamina propria. A rather thick layer of longitudinally arranged smooth muscle fibers form the muscularis mucosae [example]. The connective tissue of the submucosa consists of mostly collagenous fibers with some elastic fibers and varying amounts of fat as well as submucosal sero-mucous glands which can be readily observed in both slide 126 [example] and slide 153 [example] (those in slide 155 are not very well preserved).

In the upper esophagus, as shown in Slide UCSF 226, the muscularis externa consists of both inner and outer layers of skeletal muscle only. In the middle esophagus, the muscularis externa contains a mixture of skeletal and smooth muscle as seen in slide 126 [example], whereas in the lower esophagus only smooth muscle is found as seen in slide 155 [example]. Present in all regions of the esophagus (upper, mid, and lower) is the myenteric (Auerbach’s) plexus [example] between the two layers of the muscularis externa (W pg 267, 14.3). For most of its extent, the esophagus is retroperitoneal, so its outermost layer consists of a connective tissue adventitia which merges with the adjacent connective tissue associated with nearby structures (such as the trachea as shown in slide 126). Below the diaphragm, however, the esophagus is suspended within abdominal cavity and is therefore covered by a connective tissue serosa as shown in slide 155.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

 

129-1. What is the LEAST important contributory risk factor for this neoplasm?

  1. Alcohol and tobacco abuse
  2. Barrett’s esophagus
  3. Human papilloma virus
  4. Fungi, nitrates, nitrosamines in food

ANSWER

 

 

129-2. The MOST important risk factor for adenocarcinoma of the esophagus is:

  1. Alcohol and tobacco abuse
  2. Barrett’s esophagus
  3. Human papilloma virus
  4. Fungi, nitrates, nitrosamines in food

ANSWER

 

 

129-3. The condition with the WORST 5 year survival is:

  1. Carcinoma of esophagus
  2. Carcinoma of stomach
  3. Carcinoma of colon
  4. Carcinoma of pancreas

ANSWER

 

 

 

CASE NUMBER 253
[ImageScope] [WebScope]

Clinical History: A 60-year-old female had a one year history of weight loss and upper gastro-intestinal obstruction for three months prior to surgery.

Image Gallery:

(Summary of Gross Findings - click here)
The resected portion of the stomach showed a large fungating, partially ulcerated tumor mass in the antrum. Regional lymph nodes and a liver biopsy were free of tumor.
(Summary of Microscopic Findings - click here)
There is a rather abrupt change of the normal stomach mucosa to malignant tumor tissue, projecting into the lumen as a cauliflower-like mass. The tumor forms abundant irregular acini, lined by one or more layers of atypical cells with mostly large irregular nuclei and poorly defined eosinophilic cytoplasm. Atypical mitoses are moderately frequent. The tumor has infiltrated through the muscularis mucosa and the edematous submucosa and has invaded the muscle layers. The invading tumor had elicited a rather marked neutrophilic and plasma cell response.
(Review Normal Histology - click here)
Norm No. 16 Stomach, fundus
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The normal gastric mucosa of the fundus contains superficial fovea arranged in leaf like fronds and deeper gastric glands. The foveolar cells secrete mucin. The gastric glands include mucous cells, parietal cells, chief cells and enteroendocrine cells.

 

253-1. Under the Lauren’s classification, this tumor of the stomach would be considered:

  1. Adenocarcinoma of stomach (intestinal type)
  2. Adenocarcinoma of stomach (diffuse type)
  3. Adenocarcinoma of stomach (mucinous type)
  4. Adenocarcinoma of stomach (papillary type)
  5. Adenocarcinoma of stomach (adenosquamous type)

ANSWER

 

 

253-2. In a form of hereditary gastric cancer, patients have germline mutation and loss of E-cadherin and develop signet ring cell carcinoma. E-cadherin plays a role in maintaining cellular adhesion and is BEST considered a type of:

  1. Tumor oncogene
  2. Tumor suppressor gene
  3. DNA repair gene
  4. Telomerase
  5. Regulator of cell cycle

ANSWER

 

 

253-3. The risk factor with the HIGHEST ASSOCIATION with intestinal type gastric carcinoma:

  1. Cigarette smoking
  2. Nitrites from nitrates in water and food
  3. Smoked and salted foods
  4. H. pylori

ANSWER

 

253-4. The factor LEAST associated with development of gastric carcinoma is:

  1. Blood group O
  2. Chronic gastritis
  3. Partial gastrectomy
  4. Hyperplastic polyps

ANSWER

 

 

253-5. The MOST common site for gastric carcinoma is:

  1. Greater curvature of fundus
  2. Cardia
  3. Lesser curvature of antrum
  4. Body

ANSWER

 

 

 

CASE NUMBER 135
[ImageScope] [WebScope]

Clinical History: A 57-year-old female had early satiety, deep epigastric pain, nausea and vomiting for two months. An upper GI series revealed a small ulcer in the stomach. The free gastric acidity was low, and there was occult blood in the stool. A total gastrectomy was performed after the diagnosis of malignancy was made from a frozen section.

Image Gallery:

(Summary of Gross Findings - click here)
A shallow ulcer 1 cm in diameter was in the anterior wall of the stomach, 7 cm proximal to the pylorus. There was a broad zone of induration and thickening of the gastric mucosa which surrounded the ulcer. The section showed a diffuse gray-white mucosa tightly adherent to its submucosa. The submucosa is considerably thickened.
(Summary of Microscopic Findings - click here)
The ulcer is covered by a thin layer of inflammatory exudate. Granulation tissue and lymphocytic infiltration are present at the ulcer base. There is extensive fibrosis throughout the entire wall of the stomach with scattered tumor cells arranged in small clusters and in chains. These tumors cells are often hard to distinguish from the inflammatory cells.
(Review Normal Histology - click here)
Norm No. 16 Stomach, fundus
[ImageScope] [WebScope]

The normal gastric mucosa of the fundus contains superficial fovea arranged in leaf like fronds and deeper gastric glands. The foveolar cells secrete mucin. The gastric glands include mucous cells, parietal cells, chief cells and enteroendocrine cells.

 

What is the MOST LIKELY diagnosis?

ANSWER

 

 

135-1. When this neoplasm metastasizes to a supraclavicular node, it is termed a:

  1. Sister Mary Joseph nodule
  2. Krukenberg tumor
  3. Virchow node
  4. Pancoast tumor

ANSWER

 

 

135-2. When this neoplasm metastasizes to ovaries, it is termed a:

  1. Sister Mary Joseph nodule
  2. Krukenberg tumor
  3. Virchow node
  4. Pancoast tumor

ANSWER

 

 

135-3. When this neoplasm metastasizes to the periumbilical region, it is termed a:

  1. Sister Mary Joseph nodule
  2. Krukenberg tumor
  3. Virchow node
  4. Pancoast tumor

ANSWER

 

 

CASE NUMBER 84
[ImageScope] [WebScope]

Clinical History: This 84-year-old female developed weakness and weight loss six months prior to death. She saw a physician twelve days prior to death with signs and symptoms of intestinal obstruction. A tumor mass was palpated in the rectum. The colon was resected.

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(Summary of Gross Findings - click here)
A tumor was present 4 cm from the anus. It was hard and had completely surrounded the bowel, reducing the lumen to less than 0.5 cm in diameter. Small tumor implants were present over the peritoneum and mesentery nearby. No distant metastases were noted.
(Summary of Microscopic Findings - click here)
The the lumen of the bowel can be recognized. Note the thickened bowel wall and masses of tumor surrounding fat. Under low power note the tendency in some areas toward a gland-like structure. There is considerable variation in nuclear staining, size and shape. In some areas clumps of tumor cells are in the midst of mucus which the tumor cells are producing. Note the relatively large amount of dense collagen which accompanies the tumor cells in the fat.
(Review Normal Histology - click here)
Norm No. 27 Colon
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The colon is lined by glandular epithelium with numerous mucin secreting goblet cells. The epithelium is infolded into straight tubular glands of uniform diameter to increase the surface area available for secretion and absorption.

 

84-1. In what section of the colon do MOST adenocarcinomas arise?

  1. Ascending colon
  2. Transverse colon
  3. Descending colon
  4. Rectosigmoid colon

ANSWER

 

 

84-2. What type of colonic polyp has the GREATEST malignant potential?

  1. Hyperplastic polyp
  2. Villous adenoma
  3. Tubular adenoma
  4. Peutz-Jeghers polyp

ANSWER

 

 

84-3. Which of the following has resulted in reduced incidence of colon cancer?

  1. Vitamin E
  2. Vitamin C
  3. N-Acetylcysteine
  4. Aspirin

ANSWER

 

 

84-4. If this patient’s neoplasm were found to have penetrated into the subserosa and to have spread to one regional lymph node but NOT to distant sites, its stage is:

  1. T2 N1 M0
  2. T3 N0 M1
  3. T3 N1 M0
  4. T4 N1 M1

ANSWER

 

 

CASE NUMBER 134
[ImageScope] [WebScope]

Clinical History: An 81-year-old, asymptomatic female was found to have guaiac positive stool on routine examination. Flexible sigmoidoscopy revealed a rectal mass.

Image Gallery:

(Summary of Gross Findings - click here)
A 4 cm fungating, centrally ulcerated mass was found on gross examination.
(Summary of Microscopic Findings - click here)
This section, which includes the edge of the tumor shows invasive adenocarcinoma arising in a villous adenoma. Tall villi lined by neoplastic epithelium replace the normal mucosa at the edge of the mass. Centrally, where the lesion was ulcerated, tumor infiltrates through the muscularis propria and in some sections, enters the subserosal adipose tissue. Irregular glandular spaces are lined by tumor cells and large pools of mucin are seen, as well as desmoplastic (fibrotic) stroma. Although the nuclei of the carcinoma are anaplastic when compared to the normal colon mucosa, the neoplastic epithelium retains a columnar appearance, typically seen in colon carcinoma.
(Review Normal Histology - click here)
Norm No. 27 Colon
[ImageScope] [WebScope]

The colon is lined by glandular epithelium with numerous mucin secreting goblet cells. The epithelium is infolded into straight tubular glands of uniform diameter to increase the surface area available for secretion and absorption.

What is the MOST LIKELY diagnosis?

ANSWER

 

 

 

 

CASE NUMBER 159
[ImageScope] [WebScope]

Clinical history: This 45-year-old man complained of flushing, diarrhea, nausea and vomiting. Elevated levels of serotonin and its metabolite, 5-hydroxyindoleacetic acid were found in the blood. An appendectomy was performed.

Image Gallery:

(Summary of Gross Findings - click here)
The appendix is enlarged by a solid yellow tan tumor mass that protrudes into the lumen.
(Summary of Microscopic Findings - click here)
The tumor cells are relatively small with a round to oval stippled nucleus. There is minimal variation in size and shape. By electron microscopy, the cells contain secretory granules.
(Review Normal Histology - click here)
Norm No. 8 Appendix
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The appendix is a tubular organ with a lumen which is lined by mucin secreting columnar epithelium. There is no evidence of acute inflammation.  The submucosa and muscle layers are unremarkable.  There is no inflammation of the serosa. 

 

What is the MOST LIKELY diagnosis?

ANSWER

 

 

159-1. Which of the following statements about this particular type of tumor is/are TRUE?

  1. The carcinoid syndrome is the result of serotonin release
  2. Carcinoid heart disease results in thickened endocardium, tricuspid and pulmonic valves
  3. This GI tract tumor must have metastasized to the liver in order to produce these symptoms.
  4. This tumor arises from neuroendocrine cells
  5. ALL of the above.

ANSWER

 

 

ENDOCRINE Review Items

Key Vocabulary Terms (click here to search any additional terms on Stedman's Online Medical Dictionary)

17-hydroxycorticosteroids free thyroxine index (FTI) parathyroid hormone related protein
17-ketosteroids gestational diabetes plasma renin activity
acromegaly glycosyation (glycation) plasma renin concentration
Addison disease goiter polydipsia/polyphagia/polyuria
adrenocorticotropin (ACTH) goitrogen primary aldosteronism (Conn syndrome)
aldosterone growth hormone (GH) primary diabetes
angiotensin growth hormone releasing hormone pseudohypoparathyroidism
angiotensin converting enzyme hypercalcemia of malignancy radioactive iodine uptake (RAIU)
angiotensinogen hyperadrenalism  radioimmunoassay
bronze diabetes hyperadrenocorticism renin
catecholamine hypercalcemia secondary aldosteronism
congenital adrenal hyperplasia hyperinsulinism secondary diabetes
corticotropin-releasing hormone (CRH) hyperosmolar nonketotic coma Sipple syndrome
cortisol hyperparathyroidism somatomedin (IGF)
cortisol binding globulin (CBG) hyperpituitarism somatostatin
cretinism hyperthyroidism sporadic goiter
Cushing disease hypocalcemia steroid hydroxylase enzymes
Cushing syndrome hypoparathyroidism thyroglobulin
dexamethasone suppression test hypopituitarism thyroid stimulating hormone (TSH)
diabetes insipidus hypothyroidism thyrotoxicosis
diabetes mellitus impaired glucose tolerance thyrotropin releasing hormone (TRH)
diabetic ketoacidosis insulin resistance thyroxine (T4)
ectopic ACTH ionized calcium thyroxine binding globulin (TBG)
endemic goiter myxedema triiodothyronine (T3)
epinephrine norepinephrine vanillylmandelic acid (VMA)
euthyroidism parathyroid hormone (PTH)

LEARNING OBJECTIVES

Absolutely critical information you must know to practice medicine is in bold font.
Important information that will be needed for routine patient care is in regular font.
Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics

  1. Compare thyroglossal duct cyst and branchial cleft cyst in terms of:
    • anatomic site in the neck
    • gross and microscopic features
    • complications

  2. Compare and contrast hyperthyroidism and hypothyroidism in terms of:
    • etiologies
    • pathogenesis
    • clinical features
    • laboratory features
    • complications and prognosis

  3. List the commonly used thyroid function tests and their indications.

  4. Compare and contrast infectious, subacute (granulomatous), subacute lymphocytic, Hashimoto's, and Riedel's thyroiditis, in terms of:
    • age and sex distribution
    • etiology and pathogenesis
    • clinical, functional, and laboratory features
    • gross and microscopic features
    • complications and prognosis

  5. Discuss the utilization of fine-needle aspiration (FNA) of the thyroid, in terms of:
    • basic methodology
    • indications
    • sensitivity
    • specificity

  6. Discuss the calcium homeostatic mechanisms.

  7. Discuss hypocalcemia and hypercalcemia, in terms of:
    • etiologies
    • clinical presentation
    • laboratory testing

  8. Compare and contrast primary hyperparathyroidism, secondary hyperparathyroidism, tertiary hyperparathyroidism, and hypoparathyroidism, in terms of:
    • etiology
    • pathogenesis
    • clinical features
    • laboratory features
    • complications and prognosis

  9. Discuss the biosynthesis of adrenal steroids, and enzymatic defects leading to adrenal hyperplasia
    Common medical term % OMIM Enzyme(s) Locus Substrate(s) Product(s) Mineralocorticoids Androgens
    21-hydroxylase CAH 90-95% 201910 P450c21 6p21.3 17OH-progesterone
    progesterone
    11-deoxycortisol
    DOC
    down up
    11-beta-hydroxylase CAH 5% 202010 P450c11beta 8q21-22 11-deoxycortisol
    DOC
    cortisol
    corticosterone
    up up
    3-beta-HSD CAH very rare 201810 3betaHSD II 1p13 pregnenolone
    17OH-pregnenolone
    DHEA
    progesterone
    17OH-progesterone
    androstenedione
    down down
    17-alpha-hydroxylase CAH very rare 202110 P450c17 10q24.3 pregnenolone
    progesterone
    17OH-pregnenolone
    17OH-pregnenolone
    17OH-progesterone
    DHEA
    up down
    lipoid CAH
    (20,22-desmolase)
    very rare 201710 StAR
    P450scc
    8p11.2
    15q23-q24
    transport of cholesterol
    cholesterol
    into mitochondria
    pregnenolone
    down down

  10. Name tests used in evaluating plasma glucocorticoids, indications, and interpretation.

  11. Discuss how plasma concentrations of cortisol and aldosterone are controlled.

  12. Name the tests for evaluating adrenal androgens, their indications, and their interpretation.

  13. Discuss the biosynthesis of the adrenal catecholamines and their urinary metabolites.

  14. Discuss the use of growth hormone stimulation tests.

  15. Describe the clinical and pathologic features of including hormonal changes and clinical laboratory values in these hyperfunctional and hypofunctional conditions:
    acromegaly congenital adrenal hyperplasia
    gigantism congenital adrenal hypoplasia
    Sheehan syndrome inappropriate ADH
    empty sella syndrome Addison disease
    diabetes insipidus Waterhouse-Friderichsen syndrome
    Graves disease Cushing disease
    diffuse nontoxic (simple) goiter Cushing syndrome (hypercortisolism)
    multinodular goiter primary aldosteronism (Conn syndrome)
    myxedema ectopic ACTH production
    parathyroid hyperplasia
    acute adrenal cortical insufficiency
  1. Contrast and compare the clinical and pathologic features of type 1 and 2 diabetes mellitus.

  2. Outline methods of screening and following patients with diabetes mellitus using laboratory tests:
    • blood glucose concentration
    • glucose tolerance test
    • blood insulin concentration
    • glycosylated (glycated) hemoglobin level
    • urine glucose concentration
    • urine protein concentration
    • urine and blood ketones

  3. Describe the clinical and pathologic features of including hormonal changes and clinical laboratory values in these hyperfunctional and hypofunctional conditions:
    anterior lobe pituitary neoplasms adrenal cortical carcinomas
    craniopharyngioma pheochromocytoma
    thyroid adenomas neoplasms of extra-adrenal paraganglia
    thyroid carcinomas neuroblastoma
    parathyroid adenoma ganglioneuroma
    parathyroid carcinoma pancreatic islet cell neoplasms
    adrenal cortical adenomas pinealomas

  4. Describe the various types of multiple endocrine neoplasia (MEN) syndromes, in terms of clinical, laboratory, and morphologic features, as well as prognosis.

 

PANCREAS Review Items

Key Vocabulary Terms (click here to search any additional terms on Stedman's Online Medical Dictionary)

amylase pancreatitis
cystic fibrosis (CF) pseudocyst
gastrinoma somatostatinoma
glucagonoma sweat chloride test
insulinoma VIPoma
lipase Whipple triad
mucoviscidosis Zollinger-Ellison syndrome

LEARNING OBJECTIVES

Absolutely critical information you must know to practice medicine is in bold font.
Important information that will be needed for routine patient care is in regular font.
Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics

  1. Compare and contrast the clinical and pathologic features of:
  2. Discuss the clinical and pathologic features of cystic fibrosis.

  3. Compare and contrast acute and chronic pancreatitis, in terms of:
    • etiologic/predisposing factors
    • pathogenesis
    • morphologic features
    • laboratory manifestations
    • clinical findings and course
    • complications

  4. Compare and contrast the clinical and pathologic features of adenocarcinoma of the:
    • pancreatic head
    • pancreatic body/tail
    • ampulla of Vater

  5. 5. Discuss islet cell tumors of the pancreas, in terms of:
    • incidence
    • morphology
    • benignity vs. malignancy
    • immunohistochemical characteristics
    • endocrine function
    • clinical features and course

  6. Discuss indications and complications of pancreatic islet cell transplantion.

 

GI SYSTEM Review Items

Key Vocabulary Terms (click here to search any additional terms on Stedman's Online Medical Dictionary)

achalasia gastritis, chronic idiopathic necrotizing enterocolitis (NEC)
acute gastritis gastroesophageal reflux disease (GERD) odynophagia
adhesion Helicobacter pylori peptic ulcer
angiodysplasia hematemesis pernicious anemia
appendicitis, acute hematochezia Peutz-Jegher syndrome
atresia hemorrhoids Plummer-Vinson syndrome
Barrett esophagus hernia pseudomembranous colitis
carcinoid syndrome Hirschsprung disease pseudomyxoma peritonei
carcinoid tumor hypergastrinemia pyloric stenosis
chronic gastritis hyperplastic polyp reflux esophagitis
chronic inflammatory bowel disease inflammatory polyp Schatzki ring
Crohn disease intestinal metaplasia signet ring cell
Cushing ulcer intrinsic factor sprue (celiac, tropical, nontropical)
d-xylose absorption test intussusception steatorrhea
diarrhea ischemic enteritis or colitis stress ulcer
diverticulum juvenile polyp  superficial gastritis
dysentery Krukenberg tumor transmural inflammation
dysphagia linitis plastica tubular adenoma
dysplasia malabsorption ulcer
enterocolitis Mallory-Weiss syndrome ulcerative colitis
enterotoxin Meckel diverticulum villous adenoma
erosion Mediterranean lymphoma Virchow node
esophageal varices megacolon volvulus
esophagitis melena Whipple disease
gastritis, atrophic mucocele Zenker diverticulum
gastritis, autoimmune napkin ring lesion

LEARNING OBJECTIVES

Absolutely critical information you must know to practice medicine is in bold font.
Important information that will be needed for routine patient care is in regular font.
Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics

  1. Describe the clinical and pathologic features of disorders of the esophagus:
  2. Describe the clinical presentation and morphology of the following esophageal lesions:
    • congenital stenosis/atresia and associated tracheal lesions
    • mucosal webs
    • diverticula

  3. Discuss the etiology, pathogenesis, gross appearance, histopathology, clinical course, and the route of metastasis of esophageal carcinoma.

  4. Describe esophageal varices, their pathogenesis and typical complications.

  5. Discuss the clinical and pathologic features of the following congenital gastric anomalies:
  6. Compare and contrast acute (erosive), autoimmune, atrophic, and chronic gastritis.
    • etiology
    • pathogenesis
    • morphology
    • clinical presentation and course

  7. Discuss the pathogenesis and the morphology of stress ulcers.

  8. Contrast and compare duodenal and gastric peptic ulcers, and their typical complications.

  9. Compare and contrast clinical and pathologic features of the following types of gastric polyp:
  10. Describe typical gross and histologic features of gastric adenocarcinoma.

  11. Discuss the epidemiology and risk factors of gastric adenocarcinoma.

  12. Correlate the pathologic findings and clinical symptoms of gastric adenocarcinoma.

  13. Discuss gastrointestinal stromal tumors (GIST), in terms of:
    • histogenesis
    • morphology
    • prognosis and treatment

  14. Discuss gastrointestinal lymphoma, in terms of:
    • epidemiology
    • etiology and pathogenesis
    • level of the alimentary tract most frequently affected
    • morphologic features
    • clinical features and course

  15. Compare and contrast the clinical and pathologic features of the following diseases:
  16. Compare and contrast ulcerative colitis and Crohn disease, in terms of:
    • epidemiology
    • pathogenesis
    • morphology
    • clinical features and course
    • compications
    • malignant potential

  17. List the important viral, bacterial and parasitic pathogens causing enterocolitis.

  18. Contrast and compare diarrheal disease caused by enterotoxin-producing bacteria and diarrhea due to enteroinvasive microbes.

  19. Compare and contrast the clinical and pathologic features of:
  20. Discuss the clinical and pathologic features of the following intestinal processes:
  21. Compare and contrast the clinical and pathologic features of small intestina neoplasms:
  22. Discuss the clinical and pathologic features of the following types of colonic polyps:
  23. Compare and contrast the clinical and pathologic features of the following syndromes:
  24. Describe colorectal carcinoma, in terms of:
    • etiology
    • pathogenesis, including genetic and molecular factors
    • morphology, including grading and staging criteria
    • clinical features and course

  25. Contrast and compare clinical and pathologic features of carcinoma of right and left colon.

  26. Discuss carcinoid tumors of the colon, rectum, and appendix, in terms of:
    • pathogenesis
    • morphology
    • clinical features (including extra-colonic manifestations)
    • course and prognosis

  27. Describe the etiology, pathogenesis, and morphology of appendicitis

    actinomycotic appendicitis. chronic suppurative appendicitis resulting from infection by Actinomyces israelii.
    acute appendicitis. acute inflammation of the appendix, usually resulting from bacterial infection, which may be precipitated by obstruction of the lumen by a fecalith; variable symptoms often consisting of periumbilical, colicky pain and vomiting may be followed by fever, leukocytosis, persistent pain, and signs of peritoneal inflammation in the right lower quadrant of the abdomen; perforation or abscess formation is a frequent complication of delayed surgical intervention.
    bilharzial appendicitis. appendicitis caused by deposition of the eggs of the blood fluke Schistosoma mansoni in the vermiform appendix.
    chronic appendicitis. fibrous adhesions, scarring, or deformity of the appendix following subsidence of acute appendicitis; fibrous obliteration of the distal lumen is not abnormal in older persons; term frequently used to refer to repeated mild attacks of acute appendicitis.
    focal appendicitis. acute appendicitis involving only part of the appendix, sometimes at the site of, or distal to, an obstruction of the lumen.
    foreign-body appendicitis. appendicitis caused by obstruction of the lumen of the appendix by a foreign substance, such as a particulate foreign body.
    gangrenous appendicitis. acute appendicitis with necrosis of the wall of the appendix, most commonly developing in obstructive appendicitis and frequently causing perforation and acute peritonitis.
    left-sided appendicitis. appendicitis occurring on the left side of the abdomen, usually the left lower quadrant, due to abnormal rotation of the gut (e.g., situs inversus).
    lumbar appendicitis. acute appendicitis in a retrodisplaced appendix in the lumbar region.
    obstructive appendicitis. acute appendicitis due to infection of retained secretion behind an obstruction of the lumen by a fecalith or some other cause, including carcinoma of the cecum.
    perforating appendicitis. inflammation of the appendix leading to perforation of the wall of the appendix into the peritoneal cavity, resulting in peritonitis.
    recurrent appendicitis. repeated episodes of right lower quadrant abdominal pain attributed to recurrence of inflammation of the appendix in a person who did not have an appendectomy for prior episodes. SYN: relapsing appendicitis.
    relapsing appendicitis. SYN: recurrent appendicitis.
    stercoral appendicitis. appendicitis following a lodgment of fecal material in the appendix.
    subperitoneal appendicitis. appendicitis of a subperitoneally displaced appendix.
    suppurative appendicitis. acute appendicitis with purulent exudate in the lumen and wall of the appendix.
    verminous appendicitis. appendicitis caused by obstruction or in response to the presence of parasitic worms such as Ascaris lumbricoides, Strongyloides stercoralis, or the pinworm Enterobius vermicularis.

  28. and list the most common complications.
  29. Compare and contrast the clinical and pathologic features of
  30. List the clinical situations in which stool examination may be helpful in the diagnosis of alimentary diseases.

 

 

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