SYSTEMIC PATHOLOGY LABORATORY 

MIDTERMS, SECOND SEMESTER, AY 2019‐2020 
 
Case 1:
A 32-year-old Chinese man was referred to our institution complaining of an enlarging mass in his right
breast. He had no significant past medical or family history. He was not taking any medication. He was
unmarried, but reported normal sexual life and did military service as usual manner. He did not drink
alcohol and had a smoking history of 5 pack years. Physical examination revealed 2.5 cm round mass in
lower inner quadrant of right breast. He was an obese person with body mass index (BMI) of 30.4 kg/m2.

Mammography revealed a 3 cm microlobulated, irregular high-density mass at right subareola (Fig. 1). On
ultrasonography, the irregular mass at right subareola was measured 4.19 cm in diameter. The mass had
the complex solid and cystic echo pattern with posterior enhancement. The margin of mass was not
circumscribed and a long axis of the mass was parallel to the skin. Ultrasonography also showed a
suspicious enlarged lymph node at right axilla measured 1.31 cm in diameter (Fig. 2). The irregular
subareolar mass was classified as Breast Imaging-Reporting and Data System category 5.

Fig. 1.
Mammogram showed a 3 cm microlobulated, irregular high-density mass
(arrows) at right subareola. (A) Craniocaudal view. (B) Mediolateral oblique
view 

Fig. 2.
On ultrasonography, (A) the irregular mass at right
subareola was measured 4.19 cm in diameter and
(B) a suspicious enlarged lymph node at right axilla
was measured 1.31 cm in diameter.

Due to a BIRADS-5 score on ultrasonography, the patient underwent breast mass excision with rush frozen section, which
revealed a malignant breast tumor. He underwent modified radical mastectomy. Histopathologic study reveals the following
findings:

   
 SYSTEMIC PATHOLOGY LABORATORY 
MIDTERMS, SECOND SEMESTER, AY 2019‐2020 
 

   
GUIDE QUESTIONS:
1. What is your initial impression? What are your bases?
2. What are your differential diagnosis?
3. What other diagnostic tests will you request to rule in/rule out your clinical impressions and differential diagnosis?
 Additional question: Is there a defined set of criteria / guidelines used to guide you in diagnosing this
condition? If any, briefly explain the criteria / guideline.
4. What is your final diagnosis?
5. Describe the pathologic findings expected in the disease.
6. Give your clinicopathologic correlation for this case.
 SYSTEMIC PATHOLOGY LABORATORY 
MIDTERMS, SECOND SEMESTER, AY 2019‐2020 
 
Case 2:
An otherwise healthy 23-year-old male comes to the General Practitioner's office after experiencing
flu-like symptoms with swelling on the left side supraclavicular region of the neck. His past and recent
medical histories were fine and no other remarkable co-morbidities were reported. His family history was
unremarkable. The patient did not report any systemic symptoms including night sweats; weight loss or
fever.
The physical examination reveals the presence of fixed lymph nodes of hard consistency in the left
latero-cervical and supraclavicular area with an estimated size of 2.4 cm and without the evidence of any
other superficial lymphadenopathy or organomegaly.
An ultrasound exam of the neck and a chest X-ray were also prescribed. The biochemical results
showed increased ESR and CRP as well as a neutrophilic leukocytosis of approximately 13,000 leukocytes
per microliter.
The neck ultrasound confirmed the presence of enlarged lymph nodes in the left supraclavicular
side (2.4 × 1.3 cm) of the neck, with pathological aspects that were consistent with a lymphoproliferative
disorder. To accelerate diagnostic procedures the patient was admitted to the internal medicine department.
Chest Computed Tomography (Figure 2) showed enlarged nodes in the left supraclavicular and cervical
regions, in the upper mediastinum including paratracheal prevascular, subcarinal, bilateral lung hilum sites,
and bilaterally in the axillas. The largest node was 10 × 5 cm in diameter.

Figure 2. Chest CT scan showed enlarged nodes in the supraclavicular and cervical regions, in the upper
mediastinum including paratracheal prevascular, subcarinal, bilateral lung hilum sites, and bilaterally in the
axillas.

Supraclavicular lymph node biopsy, histologic examination and immunohistochemical analysis made the
diagnosis of a lymphoid malignancy. Histopathologic examination reveals the following findings:
 SYSTEMIC PATHOLOGY LABORATORY 
MIDTERMS, SECOND SEMESTER, AY 2019‐2020 
 

GUIDE QUESTIONS:
1. What is your initial impression? What are your bases?
2. What are your differential diagnosis?
3. What other diagnostic tests will you request to rule in/rule out your clinical impressions and differential diagnosis?
 Additional question: Is there a defined set of criteria / guidelines used to guide you in diagnosing this
condition? If any, briefly explain the criteria / guideline.
4. What is your final diagnosis?
5. Describe the pathologic findings expected in the disease.
6. Give your clinicopathologic correlation for this case.
 SYSTEMIC PATHOLOGY LABORATORY 
MIDTERMS, SECOND SEMESTER, AY 2019‐2020 
 
Case 3:
A 14‐year‐old female adolescent, is referred to  our pediatric out‐patient department due to 
weight gain, constipation, oligomenorrhea and headache. The physical examination revealed dorsal 
hump, enlarged anterior neck mass, acanthosis nigricans in the neck and armpits, dry skin on the 
extremities. 
As part of the approach of the pediatric patient with obesity, anthropometry was obtained 
obtaining BMI 38.5 kg/m2 (higher than the 97% Percentile). The waist‐height relationship was 0.65 and 
the waist percentile was higher than the 90th percentile for age and sex. The blood pressure figures 
(92/68 mmHg) were within normal values for age and sex.  
Laboratory tests were requested and showed normal results (Glucose 90 mg/dl, Hb1Ac 5.2%, 
triglycerides 90 mg/dl, total cholesterol 152 mg/dl, HDL 38 mg/dl, LDL 96 mg/dl, ALT 21 IU/l). Initially 
performing thyroid function tests due to findings of an anterior neck mass, reveals elevated TSH (203.19 
IUI/ml) and decreased FT4 (2.65 ug/dl).  
 
A neck ultrasound was performed showing evidence of an enlarged thyroid lobe (right) and presence of
multiple nodules.

Subtotal thyroidectomy was performed due to presence of “suspicious nodules” at the right lobe. Grossly, the
right thyroid lobe is enlarged and weighs 50 grams. Histopathology reveals the following findings:
 SYSTEMIC PATHOLOGY LABORATORY 
MIDTERMS, SECOND SEMESTER, AY 2019‐2020 
 

GUIDE QUESTIONS:
1. What is your initial impression? What are your bases?
2. What are your differential diagnosis?
3. What other diagnostic tests will you request to rule in/rule out your clinical impressions and differential diagnosis?
 Additional question: Is there a defined set of criteria / guidelines used to guide you in diagnosing this
condition? If any, briefly explain the criteria / guideline.
4. What is your final diagnosis?
5. Describe the pathologic findings expected in the disease.
6. Give your clinicopathologic correlation for this case.
 SYSTEMIC PATHOLOGY LABORATORY 
MIDTERMS, SECOND SEMESTER, AY 2019‐2020 
 
Case 4:
A 34 year old female sought consult at the OPD due to a neck mass which she noticed since seven months prior to
consult. She only sought consult now due to her busy schedule. There is no associated other signs and symptoms. The
family has history of malignancy on both sides. On PE there is a palpable mass on the anterior neck measuring around 7 x
4 x 4cm which moves with deglutition. No palpable cervical lymph nodes. The vital signs are normal and the rest of the
physical exam is unremarkable. Initial laboratory tests were done as OPD and the results are as follows: FT4: 2.33 miU/L
(0.4 - 4.0 mIU/L) and TSH: 11.7 pmol/L(9-23 pmol/L).

Ultrasound was also done revealing the following findings:

Given that the ultrasound findings was given a score of TIRADS-4c (highly suspicious for malignancy), a total
thyroidectomy was done. Intra-operative findings reveal:
 SYSTEMIC PATHOLOGY LABORATORY 
MIDTERMS, SECOND SEMESTER, AY 2019‐2020 
 
Histopathologic studies were done, revealing the following findings:

   

GUIDE QUESTIONS:
1. What is your initial impression? What are your bases?
2. What are your differential diagnosis?
3. What other diagnostic tests will you request to rule in/rule out your clinical impressions and differential diagnosis?
 Additional question: Is there a defined set of criteria / guidelines used to guide you in diagnosing this
condition? If any, briefly explain the criteria / guideline.
4. What is your final diagnosis?
5. Describe the pathologic findings expected in the disease.
6. Give your clinicopathologic correlation for this case.
 SYSTEMIC PATHOLOGY LABORATORY 
MIDTERMS, SECOND SEMESTER, AY 2019‐2020 
 
Case 5:
XX, a 16 year old, female, teenager, 146 cm tall and weighing 46 kg, is admitted in our institution, due to 
complaints of paroxysmal attacks of dizziness, blurring of vision and headache for last 5 months. Each 
attack persists for few minutes to half an hour and occurs irregularly once within two to three days to 3 
to 4 times a day. During each attack, the patient reports feelings of fast heart beat and palpitations, as 
well as profuse sweating. On examination, patient had hirsutism and low stature, no menstrual cycle. 
Blood Pressure (BP) is high during paroxysmal attack (Systolic BP varies from 160 mmHg to 180 mmHg 
and diastolic BP varies from 100 mmHg to 120 mmHg). Complete blood count had polycythemia HB 17.4 
g/dl and RBC 5.750000, Random Blood Sugar, Blood urea, Chest X‐rays and ECG reports were within 
normal limit. 
 
CT (Computed Tomography) scan of abdomen shows right sided suprarenal mass of a size about 10.2 cm 
× 9.3 cm with calcifications and cystic degenerations that shifts liver margin and superior pole of right 
kidney, but without clear confines. 
 

   
 
The patient was scheduled for surgery and was given pre‐OR medications to address her erratic blood 
pressure. A well circumscribed, tan to yellow suprarenal mass was identified and sent for 
histopathology. Microscopic examination of the mass showed the following findings: 
 SYSTEMIC PATHOLOGY LABORATORY 
MIDTERMS, SECOND SEMESTER, AY 2019‐2020 
 

 
 
GUIDE QUESTIONS:
1. What is your initial impression? What are your bases?
2. What are your differential diagnosis?
3. What other diagnostic tests will you request to rule in/rule out your clinical impressions and differential diagnosis?
 Additional question: Is there a defined set of criteria / guidelines used to guide you in diagnosing this
condition? If any, briefly explain the criteria / guideline.
4. What is your final diagnosis?
5. Describe the pathologic findings expected in the disease.
6. Give your clinicopathologic correlation for this case.