OBJECTIVES:
Learn basic nomenclature of neoplasia. Recognize the gross pathologic characteristics of benign versus
malignant neoplasms. Describe what is meant by differentiation (grade) is and how it is
assessed. Describe what is meant by tumor stage and how it is assessed. Outline the basic differences between sarcomas and carcinomas. Outline the basic routes of metastases by neoplasms. Describe methods for diagnosis of neoplasms.
Case 1
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History:
- A 45-year-old man incurred abdominal trauma, and an exploratory laparotomy was performed. A ruptured splenic capsule was found, with hemoperitoneum, and a splenectomy was performed. During exploration, the surgeon observed a small, discrete, 0.7 cm mass beneath the serosa in the wall of the stomach, and it was resected.
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Questions:
What is the degree of differentiation? What is the malignant counterpart of this lesion?
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Case 2
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History:
- A 52-year-old woman had irregular menstrual bleeding that persisted for months. On physical examination, the cervix appeared normal, but the uterus was enlarged and irregular. No adnexal masses were palpable. An endometrial biopsy had not shown evidence for a malignancy. She underwent a hysterectomy, and at surgery, the uterus appeared nodular. In surgical pathology on dissection, the nodules were firm, white, discrete, and appeared to arise in the myometrium.
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Questions:
If multiple tumor masses are present, then why isn't this metastatic? What is the malignant counterpart of this lesion and does it often
arise from the neoplasm in this case?
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Case 3
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History:
- A 61-year-old man began complaining of vague chronic abdominal pain. This was associated with a 9 kg weight loss over several months. Upper GI endoscopy revealed an irregular area of shallow ulceration on the lesser curvature of the stomach. This area was biopsied. At laparotomy, exploration of the abdomen revealed an area of diffuse, firm thickening of the gastric wall beneath the area of ulceration.
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Questions:
What is this neoplasm? Why is the neoplasm accompanied by weight loss? How has the incidence of this disease changed in the U.S. and some other nations in this century?
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Case 4
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History:
- A 63-year-old woman who was born and lived in the U.S. all her life underwent mammography screening after her physician palpated a mass in the left breast that had irregular margins and seemed fixed to the overlying skin, which had a rough, orange-red appearance. Both the patient's mother and a maternal aunt died of breast cancer. The mammogram revealed a poorly defined mass in the left breast. A left mastectomy with axillary lymph node sampling was performed.
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- The patient's 34-year-old daughter, worried about cancer affecting her, sees her physician, and a small lump is palpable. This is excised.
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Questions:
What is the significance of the history of breast cancer in the family? What is the degree of differentiation? What methods are available for diagnosis of the mammographic lesion to determine if mastectomy should be performed? What is the most likely diagnosis for the daughter's breast lesion?
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Case 5
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History:
- An 82-year-old woman was admitted to the hospital with a history of worsening, severe respiratory distress over the past two days. History revealed that she had undergone mastectomy seven months previously.
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Questions:
What are typical routes for metastases? How do these routes differ in regard to the primary site and cell of origin? How did the metastases account for the clinical presentation?
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Case 6
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History:
- A 38-year-old woman had heavy, irregular menstrual bleeding. She had been taking estrogen-containing medications for several years. She was treated with endometrial curretage followed by hysterectomy.
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Questions:
What is the significance of the pathologic finding in this setting? How does this process differ from neoplasia?
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Case 7
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History:
- A 49-year-old man had a 100 pack/year history of smoking. He had a chronic cough, but recently he noted some blood-streaked sputum along with chest pain. A chest CT scan was performed. After clinical work-up, the tumor that was found was not amenable to resection and radiation therapy was initiated.
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Questions:
What caused this cancer? Where would this tumor metasatasize first? What methods are available for diagnosis of this neoplasm?
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Case 8
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History:
- A 12-year-old boy noted pain in the left lower leg, even at night, for several months following a blow to the calf from a soccer ball. A radiograph revealed a mass lesion involving the metaphysis of the distal femur.
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Questions:
Patients often equate a history of trauma with appearance of a neoplasm. How often is trauma the etiology for a neoplasm? How can you tell that this neoplasm is arising in bone? What methods are available to determine the cell of origin? How is such a tumor most likely to spread? - How does the process of informed consent work if the patient is a child?
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Case 9
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History:
- A 55-year-old man had a test for occult blood performed on stool as a part of a routine examination. The test was positive. A colonoscopy was performed.
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Questions:
What are the names of these lesions? Explain the genetics of these lesions What are potential screening tests for cancer?
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