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29 May 2013 - Case of the Week #275

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Thanks to Dr. Rodney Shackelford, Tulane University School of Medicine, Louisiana (USA) for contributing this case and the discussion. To contribute a Case of the Week, follow the guidelines on our Case of the Week page.

July 15-19, 2013
Snow King Resort
Jackson, Wyoming

30th Annual Summer Update
In Clinical Immunology, Microbiology, and Infectious Diseases

This 24.25 hour review and update in the areas of clinical immunology, microbiology, and infectious diseases is intended to improve knowledge about the pathogenesis and clinical manifestations of infectious diseases, immunological mechanisms of disease and disease prevention, appropriate approaches to the diagnosis of infections and immunologic disorders, and utilization of the clinical microbiology and immunology laboratory including selection and interpretation of results.

This course will provide a forum for the exchange of ideas dealing with microbial infections as well as immunity to infectious diseases and immunologic disorders. Faculty consists of clinicians involved in patient care, pathologists, and clinical laboratory scientists. Discussion of timely topics by faculty and participants assures that this course will be informative, interesting, and relevant.

Course Directors:
Harry R. Hill, MD
Larry G. Reimer, MD
Judy A. Daly, PhD

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Case of the Week #275

Clinical History:

In 1986, a 13 year old girl in Pripyat, now an abandoned city in the Ukraine, was exposed to the Chernobyl nuclear plant explosion for 48 hours prior to being evacuated. She lived 3 km from the nuclear plant. Twenty two years later, at age 35 years, she developed recurring upper abdominal pain and underwent upper endoscopy with gastric biopsy.

Micro image:


What is your diagnosis?































Diagnosis:

Signet ring cell adenocarcinoma of the stomach, also known as diffuse type adenocarcinoma

Discussion:

Immunostains were performed (left CAM 5.2, right CEA):


The biopsy shows a gastric adenocarcinoma characterized by gastric mucous cells that infiltrate the stroma as single cells, or small clusters of cells with numerous signet ring cells where intracellular mucin pushes the nucleus to the periphery. The tumor cells were immunoreactive for CAM5.2 and CEA (shown above). Often the central intracellular mucin can be highlighted with mucicarmine or Alcian blue-PAS stains (intracellular mucin gives a “target pattern”). The tumor cells are also immunoreactive for EMA, villin and Ki-67 and negative for CD45 and TTF1.

The differential diagnosis includes:
• Lymphoma with artifactual signet ring cells due to cytoplasmic shrinkage. CD45 is usually positive in lymphoma.
• Metastases from breast or lung; clinical history, plus the use of appropriate immunostains such as TTF1 or GCDFP-15 is helpful.
• Reactive epithelial atypia associated with radiation treatment or chemotherapy.
• Xanthoma

The Chernobyl nuclear accident is known for having caused a large number of aggressive pediatric papillary thyroid carcinomas, especially in Belarus (1). There may be some Chernobyl-related gastric cancers that exhibit an unusually aggressive clinical course (2). The treatment usually involves surgical resection or chemotherapy. Presently the prognosis is poor.

References:
1. Mahoney MC, Lawvere S, Falkner KL, Averkin YI, Ostapenko VA, Michalek AM, Moysich KB, McCarthy PL: Thyroid cancer incidence trends in Belarus: examining the impact of Chernobyl, Int J Epidemiol 2004;33:1025

2. Shchepotin IB, Valetsky VL, Chorny VA, Shabahang M, Nauta RJ, Buras RR, Evans SR: Carcinoma of the stomach following the Chernobyl nuclear accident, Eur J Cancer 1997;33:1413

Nat Pernick, M.D., President
and Palak Thakore, Associate Medical Editor
PathologyOutlines.com, Inc.
30100 Telegraph Road, Suite 408
Bingham Farms, Michigan (USA) 48025
Telephone: 248/646-0325
Email: NatPernick@Hotmail.com
Alternate email: NatPernick@gmail.com