Case -T10-2B PATHOLOGY REPORT

Case
-T10-2B PATHOLOGY REPORT
LOCATION: Inpatient, Hospital
PATIENT: Emma Apolio
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
PATHOLOGIST: Grey Lonewolf, MD
CLINICAL HISTORY: Patient has right carotid body mass and history of thyroid cancer.
SPECIMEN RECEIVED: Carotid body tumor with FS (frozen section)
GROSS DESCRIPTION: The specimen is labeled with the patient's name and "right carotid body mass" and consists of a 3.5 2.8 1.4 cm (centimeter) red-brown tissue weighing 8.5 g (gram). The tumor is inked black. Cut sections show a solid red-brown center. The specimen is submitted in 5 cassettes.
INTRAOPERATIVE FROZEN SECTION DIAGNOSIS: Right carotid body tumor:
Paraganglioma (carotid body tumor), as per Dr. Lonewolf.
MICROSCOPIC DESCRIPTION: Permanent sections confirm the frozen section diagnosis of carotid body tumor. The lesion appears relatively well circumscribed, partially surrounded by a hyalinized fibrous capsule. The tumor is composed of nests (Zellballen) of polygonal cells with areas of trabeculae of fibrous tissue. The tumor cells have abundant granular eosinophilic cytoplasm and predominantly round to ovoid nuclei showing some focal pleomorphism and hyperchromatism. Mitoses are scant. Vascular invasion is not seen.
DIAGNOSIS: Right carotid body mass: Carotid body paraganglioma.
COMMENT: It is almost impossible histologically to judge the clinical source of a carotid body tumor by its histology, even though most of these tumors are seldom malignant. Mitoses, nuclear pleomorphism, and even vascular invasion are unreliable markers of malignancy. Close clinical follow-up is needed as these tumors may recur.
T10-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________