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Presented by Justin Bishop, MD and prepared by Sarah Karram, MD
Case 1: 50 year old woman with a parotid mass.
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1. Question
Week 610: Case 1
50 year old woman with a parotid mass.
Correct
Answer: Acinic cell carcinoma, infarcted
Histology: This is a relatively well circumscribed tumor that is very “pink” on low power. On higher power it is evident that the vast majority of the tumor is infarcted, with the highly eosinophilic tumor “ghost cells” still visible. One microscopic focus of the tumor was viable, and exhibited the serous acinar differentiation that is diagnostic for acinic cell carcinoma. To confirm that the remaining infarcted tumor was also acinic cell carcinoma (and not a separate, unrelated tumor), DOG-1 immunohistochemistry was performed. Despite being dead, the infarcted tumor cells demonstrated the canalicular staining pattern for DOG-1 that is classic for acinic cell carcinoma.
Discussion: With the widespread use of fine needle aspiration to preoperatively diagnose salivary gland tumors, it is not uncommon to see FNA-related changes in the resection specimens. Often this takes the form of tumor infarction. The most commonly infarcted salivary gland tumors are pleomorphic adenoma and Warthin tumor, but any tumor can show these changes. The key to diagnosing and infarcted tumor (in any organ) lies in recognizing a residual, viable component; the viable cells will typically be in the most peripheral aspects of the neoplasm. If no tumor remains viable, a diagnosis can still be suggested by the FNA diagnosis, the architecture of the infarcted tumor (especially with Warthin tumor), and in occasional cases, immunohistochemistry on the ghost cells.
Incorrect
Answer: Acinic cell carcinoma, infarcted
Histology: This is a relatively well circumscribed tumor that is very “pink” on low power. On higher power it is evident that the vast majority of the tumor is infarcted, with the highly eosinophilic tumor “ghost cells” still visible. One microscopic focus of the tumor was viable, and exhibited the serous acinar differentiation that is diagnostic for acinic cell carcinoma. To confirm that the remaining infarcted tumor was also acinic cell carcinoma (and not a separate, unrelated tumor), DOG-1 immunohistochemistry was performed. Despite being dead, the infarcted tumor cells demonstrated the canalicular staining pattern for DOG-1 that is classic for acinic cell carcinoma.
Discussion: With the widespread use of fine needle aspiration to preoperatively diagnose salivary gland tumors, it is not uncommon to see FNA-related changes in the resection specimens. Often this takes the form of tumor infarction. The most commonly infarcted salivary gland tumors are pleomorphic adenoma and Warthin tumor, but any tumor can show these changes. The key to diagnosing and infarcted tumor (in any organ) lies in recognizing a residual, viable component; the viable cells will typically be in the most peripheral aspects of the neoplasm. If no tumor remains viable, a diagnosis can still be suggested by the FNA diagnosis, the architecture of the infarcted tumor (especially with Warthin tumor), and in occasional cases, immunohistochemistry on the ghost cells.
