3 rd

CLINICOPATHOLOGIC
CONFERENCE
Luis P. Cruz, MD, FPSP
(Consultant Pathologist)

Renan B. Navarro, MD
(Resident Pathologist)

August 13, 2006

 GENERAL DATA
• 35 y/o male from Batangas

• CC: chest pain

• 4 months history of right-sided chest pain

• Alcoholic and chronic smoker

• Severe chest pain, admission and was discharged

• Gradual enlargement of the right breast

• Non-productive cough and low-grade fever, 25% weight

loss, hence admission
• CXR: Right Pulmonary Mass

• Complete autopsy was done

 AUTOPSY FINDINGS
EXTERNAL EXAMINATION:

• Body is that of an adult male

• Nutrition is at par with age

• Thoracostomy incision site over the 6th ICS RAAL

• CVP line incision site over the left cubital fossa

• Bilateral gynecomastia
AUTOPSY FINDINGS
AUTOPSY FINDINGS
• SUBCUTANEOUS FAT: 0.8 cm

• NECK ORGANS: thyroid weighs 30 gm and is

unremarkable. Parathyroids are not located

• MEDIASTINUM:
Trachea and large bronchi contain no
aspirated material nor blood
Lymph nodes are not enlarged.
An ill-defined, hemorrhagic, soft to friable
mass is seen involving the right supero-
anterior mediastinum and SVC
 AUTOPSY
AUTOPSY FINDINGS
FINDINGS

• PLEURAL CAVITIES:
The right cavity contains 1800 ml of clotted
blood
The left contains 500 ml of serous clear fluid
 AUTOPSY
AUTOPSY FINDINGS
FINDINGS

• LUNGS

A 10 x 9 x 2 cm, ill-defined,
lobulated, soft to firm, reddish-blue
mass, involving RU and middle lobe

CSS: soft to friable, variegated,

cream-red parenchyma. Focal
irregular pale yellow, solid, firm areas
also seen.

The right lower lobe and the left

lung are cyanotic, wrinkled, rubbery
and airless
 AUTOPSY
AUTOPSY FINDINGS
FINDINGS
• PERICARDIAL CAVITY
Hemorrhagic, soft, friable tumor tissue is
loosely adherent to the right lateral and posterior
aspects of the pericardium

The sac contains the same tumor tissue

There are loose tumor tissue adhesions

between the two layers of pericardium
 AUTOPSY
AUTOPSY FINDINGS
FINDINGS
• HEART
Weighs 240 gm

Epicardial surface of the posterior

and lateral wall of the right ventricle
is shaggy with hemorrhagic, soft,
friable parenchyma

Myocardium, endocardium, valves

and coronary arteries are
unremarkable
 AUTOPSY
AUTOPSY FINDINGS
FINDINGS
• LIV ER
– Weight: 1,350 gms
– 32 x 22 x 10 cm (enlarged)
– Doughy
– yellowish-brown

– CSS: yellowish and greasy

parenchyma
 AUTOPSY
AUTOPSY FINDINGS
FINDINGS

• Aorta and large vessel

• Abdominal cavity
• GIT
• Gallbladder and biliary tree
• Spleen U/R
• Pancreas
• Adrenals
• GUT
• Brian
 MICROSCOPIC DIAGNOSIS

• LUNG S
– Sections of the solid yellow areas
show mature tissues derived from
the 3 germ layers

– Some of the cartilagenous foci are

immature with basophilic cells with
large and dark nuclei

– In addition, there are foci of small

dark-staining cells with scanty
cytoplasm with a tendency to form
rosettes
– Sections taken from the
hemorrhagic, soft, friable
areas show alternating
sheets of pale, regular
cytotrophoblasts and
eosinophilic, irregular
syncitiotrophoblasts
MICROSCOPIC DIAGNOSIS
• LUNG S

– The same trophoblasts are found inside some pulmonary

blood vessels

– Sections fro the rest of the right and the left lung show
collapse of alveoli

– The remaining patent alveoli contain lightly eosinophilic,

homogenous material
DIAGNOSIS

• TERATOMA WITH IMMATURE ELEMENTS

AND CHORIOCARCINOMATOUS
COMPONENT; TUMOR EMBOLI,
PULMONARY VESSELS; ATELECTASIS;
PULMONARY EDEMA.
 MICROSCOPIC DIAGNOSIS

• PER IC ARDIU M AN D HEAR T

– Hemorrhagic areas with cytotrophoblasts and

syncitiotrophoblasts involving the parietal and
visceral pericardium

– Myocardium is not involved

– Mature teratomatous elements not seen

 DIAGNOSIS
DIAGNOSIS

• CHORIOCARCINOMA
 MICROSCOPIC DIAGNOSIS
MICROSCOPIC DIAGNOSIS

• LIV ER
– Areas with polygonal
cells with a central
vesicular nucleus and
abundant pink
cytoplasm (normal
hepaticytes)

– Areas with numerous

tiny fat vesicles (fatty
liver)
 MICROSCOPIC
MICROSCOPIC DIAGNOSIS
DIAGNOSIS

• BREAST
• - Ductal and connective tissue
proliferation with periductal edema
 DIAGNOSIS
DIAGNOSIS

• GYNECOMASTIA
 MICROSCOPIC
MICROSCOPIC DIAGNOSIS
DIAGNOSIS

• KI DNE YS

– Di latati on of proxi mal convolut ed

tubul es

– Epi thel ial cel ls are finel y gr anul ar

wi th des quam ati on
» Patchy loss of epithelial cells
» Tubular dilatation
» Patchy necrosis
 DIAGNOSIS
DIAGNOSIS

• ACUTE TUBULAR NECROSIS,

BOTH KIDNEYS.
 DIAGNOSIS
DIAGNOSIS

• HYPOXIC CHANGE
FINAL ANATOMIC
FINAL ANATOMIC DIAGNOSIS
DIAGNOSIS

A case of 31 y/o male who came in with a cc of

right-sided chest pain. Pertinent history and physical
findings include the: 4 months history of right-sided
chest pain, gradual enlargement of the right breast and
large mass on CXR at the right hilar region. Few hours
prior to demise, patient had persistent hypotension,
hemothorax (right) and hydrothorax (left). Multiple
transfusions and tube thoracostomy were done,
however, despite all the resuscitative measures, he
went into cardiorespiratory arrest.
 MICROSCOPIC
FINAL DIAGNOSIS
ANATOMIC DIAGNOSIS

I. MEDIASTINAL TERATOMA WITH MATURE AND

IMMATURE ELEMENTS AND
CHORIOCARCINOMATOUS COMPONENT,
WITH INFILTRATION INTO THE RIGHT LUNG
AND PERICARDIUM.
A. RESIDUAL HEMOTHORAX, 1800 ML, RIGHT.
B. HYDROTHORAX, 500 ML, LEFT.
C. COMPRESSION ATELECTASIS, BOTH LUNGS.
D. ACUTE TUBULAR NECROSIS, BOTH KIDNEYS.
E. HYPOXIC CHANGES, BRAIN.
F. GYNECOMASTIA, BILATERAL.
II. S/P TUBE THORACOSTOMY FOR EVACUATION
OF HEMOTHORAX.
 CAUSE OF DEATH

HYPOVOLEMIC SHOCK SECONDARY TO

TUMOR BLEED (MEDIASTINAL
TERATOMA WITH MATURE AND
IMMATURE ELEMENTS AND
CHORIOCARCINOMATOUS
COMPONENT, WITH INFILTRATION
INTO THE RIGHT LUNG AND
PERICARDIUM).
 RIGHT-SIDED CHEST PAIN
GYNECOMASTIA CHORIOCARCINOMA

NON-PRODUCTIVE COUGH
LOW GRADE FEVER

VERY SEVERE R-SIDED

CHEST PAIN
DYSPNEA & TACHYPNEA 1800 ml
(hemothorax, R)

500 ml
(hydrothorax, L)

HYDROTHORAX

HYPOVOLEMIC
SHOCK
COMPRESSION
ATELECTASIS, BOTH DEATH
LUNGS
 DISCUSSION
TER ATOMA S
• congenital tumors containing derivatives of all three
germ layers and arise from pluripotent embryonal cells

• commonly occur in ovaries, testes, retroperitoneum and

the sacro-coccygeal region

• Superior mediastinal teratomas: usually asymptomatic

till late, often discovered incidentally on CXR

• Symptoms such as chest pain, dyspnea or cough: result

of compression of nearby structures

• Definitive diagnosis: histology

• Rarely, not all three germ layers are identifiable

• teratomas have been reported to contain hair, teeth, bone and

very rarely more complex organs such as eyeball, torso, and
hand

• Usually, however, a teratoma will contain no organs but rather

one or more tissues normally found in organs such as the
brain, thyroid, liver, and lung

• Known to secrete exocrine and endocrine products of their

tissue components

• In a very small %, a malignant transformation or malignant

component is seen (e.g. sq. cell ca, adenoca and
choriocarcinoma); the mass usually has a long history and is
seen in older patients.

• Thought to be present at birth, but often they are not

diagnosed until much later in life.
• It is predominantly diagnosed between the 2nd and
4th decade and the incidence is: M=F

• Mature teratomas:most common histological type of

germ cell tumors, followed by seminomas

• Germ cell tumors are predominantly found in

gonads, while the anterior mediastinum is the most
common extragonadal site

• Mediastinal teratomas are the most common tumor

of the anterior compartment
CLASSIFIED INTO:
• MATURE TERATOMA (BENIGN)
– are commonly cystic
– aka Dermoid Cyst
– presumably derived from the ectodermal
differentiation of totipotential cells
– Bilateral in 10 to 15%
– Unilocular cyst containing hair and cheesy sebaceous
material
– Hx: cyst wall: strat. sq. epithelium with underlying
sebaceous glands, hair shafts and other skin adenxal
structures
– Can also be seen: cartilage, bone, thyroid tissue and
other organoid formations
– 1% undergo malignant transformation
• IMMATURE TERATOMA (MALIGNANT)
– Rare tumors
– Component tissue resembles that observed in the
fetus or embryo rather than in adult
– Found chiefly in prepubertal adolescents and young
women (mean age= 18 y/o)
– Grow rapidly and frequently penetrate the capsule
with local spread or metastasis
– High-grade tumors have poor prognosis
– Recurrences may develop after 2 years
– Hx: varying amounts of immature tissue
differentiating toward cartilage, glands, bone,
muscle, nerve, etc.
• MONODERMAL TERATOMAS

– A remarkable, rare group of tumors

– Struma ovarii and carcinoid: most common

– Always unilateral; although a contralateral teratoma

may be present
MEDIASTINAL TERATOMA
• The mediastinal germ cell tumors comprise
15% of anterior mediastinal tumors in adults
and 25% in children

• Benign tumors include mature teratomas and

mature teratomas with an immature
component of <50%

• Mediastinum: 3rd most common location next

to sacrococcygeal and retroperitoneal sites

• Teratomas are the 2nd most common tumor of

all the compartments of the mediastinum next
to neurogenic tumors
• Are believed to arise fro the 3rd pharyngeal
pouch, the thymus anlage

• About 65% of the mediastinal teratomas are

mature.

• Usually, mediastinal teratomas are the most

frequent mediastinal germ cell tumors, while
immature teratomas are very rare
Short notes on CHORIOCARCINOMA
• Most aggressive form of gestational trophoblastic
disease

• mixture of cytotrophoblast and syncytiotrophoblast in

plexiform pattern

• Rapidly invasive and metastasizing; may present with

metastases but have small or necrotic primary tumor

• Choriocarcinomas often have large areas of

hemorrhage and necrosis and consist of large
pleomorphic, multinucleated cells with ample
eosinophilic cytoplasm known as
syncytiocytotrophoblasts and cytotrophoblasts, which
are polygonal cells with a clear cytoplasm, round
nuclei, and conspicuous nucleoli.

• elevated B-HCG
THANK YOU!