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History

History. 58 year-old female presented with back pain and right toe numbness. Her past medical history was significant for hypertension, glaucoma and morbid obesity Her past surgical history was significant for remote cholecystectomy

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History

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  1. History • 58 year-old female presented with back pain and right toe numbness. • Her past medical history was significant for hypertension, glaucoma and morbid obesity • Her past surgical history was significant for remote cholecystectomy • After outpatient evaluation by neurosurgery, an MRI of her spine was obtained

  2. Describe the findings on the MRI imaging

  3. Answer: • Destructive soft tissue mass centered at the lamina and spinous process of L5 which appears to measure in aggregate 3.8 x 3.6 x 3 cm. • The patient was scheduled for a biopsy

  4. Describe this low-power view from the smear preparation.

  5. Answer • Cellular smear • Tissue fragments and small clumps of cells • Specimen appears lesional

  6. Describe the high-power cytologic features from the smear

  7. Answer Acinar formation Abundant eosinophilic cytoplasm Cohesive cells clusters Intra-nuclear inclusions

  8. Question: • Is the lesional tissue neoplastic?

  9. Answer • Yes; and most likely a metastatic neoplasm. However due to the lack of any known primary tumor in this patient a final diagnosis can only be made on the permanent sections.

  10. Question 2: • What other stains would be useful to make an accurate diagnosis of this lesion?

  11. Describe the histologic findings on the permanent H&E section

  12. Answer Vaguely nodular and cellular lesion

  13. Describe this high-power area

  14. Answer: • Similar to the smear preparation: • Cells forming acini-pseudoglands • Abundant granular eosinophilic cytoplasm • Round nuclei with coarse chromatin • Intranuclear inclusions

  15. Describe this other H&E high-power field

  16. Answer This field shows marked steatosis in many of the neoplastic cells

  17. By this time we are informed that her AFP level was 13422 ng/mL (normal range is <20)

  18. Question • Based on the morphologic features and clinical presentation, what is the most likely diagnosis?

  19. Answer • Metastatic hepatocellular carcinoma (HCC)

  20. Question: • What stains would you do to confirm metastatic HCC

  21. Answer • HCC typically have this immunoprofile • CK7 – • CK20 – • HepPar + • AFP + • A1-antitrypsin + • CEA +

  22. Immunohistochemical stains CK7 CK20

  23. A1-AT AFP HepPar1 CEA

  24. Are you convinced? YES!

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