Download Case-1: 成大醫院 (S15-023285) The patient is a 41-year

Case-1: 成大醫院 (S15-023285)
The patient is a 41-year-old gentleman who had noticed prominent bilateral neck
lymph node enlargement in February 2015. Cold sweating and loss of body weight
(from 65kg to 57kg) were also noted two years ago. He visited an outside hospital for
help first, where some type of lymphoma with bone marrow and extranodal
involvement was diagnosed by lymph node and bone marrow biopsy. Whole body CT
showed systemic lymphadenopathy. He then came to our oncologist's OPD for second
opinion, and later decided to receive treatment in our hospital. The oncologist ordered
a slide review and did bone marrow biopsy again (15-023285).
Case-2：奇美醫院 (2016-07-0668)
This 78-year-old female has past history of (1) hypertension; (2) old pulmonary TB; (3)
hepatitis B. Hematuria was noted recently and she went to our urology OPD for help.
The urine cytology showed MALIGNANT, most likely urothelial carcinoma.
Therefore, ureterorenoscopy was done and one papillary tumor over left upper ureter
was noted. Biopsy report revealed urothelial carcinoma. Abdominal CT showed (1)
wall-thickening of left renal pelvis and U/3 ureter with increased enhancement, in favor
of urothelial carcinoma; (2) a nodule in spleen about 1.4cm, probably metastasis. Under
the impression of urothelial carcinoma at left upper ureter and splenic metastasis, she
was admitted to our ward. Left laparoscopic nephroureterectomy and laparoscopic
splenectomy were done.
Case-3：中山附設醫院 (CSP14-13089B)
The 73-year-old woman had history of diabetes mellitus under fair control. According
to patient's statement, she suffered from sore throat off and on for several months.
Besides, she went to other hospital and right tonsil mass was told. Sore throat and
odynophgia were still noted after medical treatment. Then, she came to our ENT
department for help. The physical examination showed right tonsil asymmetric
enlargement, with poor healing wound and exudate. The laryngoscopic finding was
unremarkable. The laboratory data showed WBC 10650/uL, Hb14.3 g/dL and Platelet
175K/uL. After discussing with patient and her family, they decided to receive right
tonsillectomy.
Case-4：馬偕紀念醫院 ( T13289 )
A 58-year-old woman presented with a pruritic bilateral facial rash of 3 weeks
duration. Physical examination showed linearly distributed erythematous papules on
both sides of the face, extending in a vertical fashion from the temporal area to the
chin. She denied any similar eruptions previously or contact with other topical agents,
cosmetics, or using nail polish before the rash. The clinical differential diagnosis
included palisaded neutrophilic and granulomatous dermatitis (PNGD), interstitial
granulomatous dermatitis associated with rheumatoid arthritis, drug reaction, and
contact dermatitis. A skin biopsy was obtained from the right cheek and the patient
was instructed to stop all current medications.
Case-5：高雄榮民總醫院 (VGHKS-04-41761)
This 48-year-old man, with past history of helicobacter pylori infection of stomach,
complained of multiple brownish skin nodules and papules for three years. They have
been itching and showing verroucous change recently. These skin lesions were
initially present over his lower back, and then progressed to the chest, scalp, axillary,
and pubic area with enlarging. They were no easily contact bleeding nor tenderness.
He had no fever, nausea or vomiting, night sweats, body weight loss, bloody stool or
tarry stool, nor upper respiratory symptoms. Specific contact, travel, medication, and
malignant history were negative. No palpable lymph node was identified. He came to
our outpatient department for help and accepted skin biopsy.
Case-6：亞東醫院 (105-18117)(Virtual)
This 87-year-old man presented with left cheek skin mass for years with recent rapid
growth. The mass was nodular, tan and soft, measuring 0.7 x 0.7 cm in dimension.
The patient denied any past history of malignancy. He underwent surgical excision of
the mass.
Case-7：高醫附設醫院 (KMU-16-14492)(virtual)
This 37 year-old female has progressive right eye ptosis for 1 month.
Diplopia was noted with right gaze during examination and progressively deteriorated
in all direction. Right eye visual acuity also decreased with associated symptoms of
dizziness, headache, poor appetite, and general malaise in recent 1 week.
Physical examination revealed ptosis (OD), dilated pupil (OD), without light reflex,
and EOM limitation in all direction (OD). Under the impression of right cranial nerve
II, III, IV, VI palsy, patient was admitted for Magnetic resonance image (MRI) and
further evaluation. MRI T1 WI showed sellar tumor with isointense signal mixed with
hyperintense part. Under the impression of sellar tumor, surgical biopsy was
performed for pathological evaluation.
Case-8：雙和醫院 (virtual)
The 18-day-old male neonate was born at 38 weeks of gestation without obvious
fetal abnormality. After birth, he was admitted to Newborn ICU of Taipei MacKay
Memorial Hospital (MMH) for transient tachycardia and congenital pneumonia. After
discharge, enlarged head circumference ( from 36 cm at birth to 39.5 cm) and lethargy
were noticed , then he was sent to MMH. The brain MRI showed a forth ventricular
tumor measuring about 5x5x3 cm in size. He was transferred to Taipei Medical
University Hospital for surgery. During operation, an infiltrative tumor involving
almost whole cerebellar vermis was found.
Case-9：台大醫院 (S16-14324 和 S16-20283)
This 35-year-old man had intermittent radiating headache from the forehead to
left shoulder for six months and suffered from diplopia recently. Brain MRI showed
multiple extra-axial, contrast-enhanced tumors along the left sphenoid ridge, between
the left cerebellar hemisphere and medulla, and in the left sphenoid sinus.
Midline suboccipital craniotomy was performed and a dura-based tumor, about 3
cm in size and over the left dorsal side of foramen magnum, was removed
(S16-14324).
During his post-operation admission period, pneumonia developed with consistent
lobar consolidation and septic shock. Chest CT was performed to investigate the
nature of consolidation, but unexpectedly found a 4.6 cm soft tissue mass on the right
posterior chest wall with the 6th rib destruction. Biopsy was performed (S16-20283)
Case-10：台大醫院 (S15-37618A2)
This 50-year-old female found a left breast tumor, about 3 o'clock, 15 years ago. She
went to LMD, and the doctor told her that it was probably benign because it was
movable. In 2015, she went to our OBS/GYN OPD due to vaginal bleeding. Health
examination was promoted, so she received mammography on 2015/07/03, which
revealed a 3.5 cm mass in left breast lower inner quadrant (8 o'clock direction, 3 cm
from nipple) and a 2.1cm mass in left breast upper outer quadrant (2 o'clock direction,
4 cm from nipple). No bloody nipple discharge or skin ulcer over the surface was
noticed. Sonography revealed two hypoechoic tumors with a multilobulated border.
Under the impression of left breast tumor with BI-RADS 4C lesion, tumor excision
were done.
Case-11：羅東聖母醫院
(1603341-A4)
An 82 year-old man visited our out-patient clinic because of a large breast mass noted
for several weeks. On physical examination, a tumor measuring 3x3x2 cm was found
at the left breast at 12 o’clock position, 1 cm from the nipple. Laboratory data
revealed slight anemia; hemoglobin of 11.1g/dl, and hematocrit 33.3. Biochemical
data were within normal limits. He underwent a CT of chest which confirmed the
clinical impression of a large left breast mass. In addition, multiple nodular lesions
were found in the right lung field. The radiological findings were interpreted as
primary breast cancer with lung metastasis. He underwent core biopsy of the breast
mass and histological examination was interpreted as infiltrating ductal carcinoma.
Subsequently, he had a simple mastectomy without lymph nodes dissection.
Case-12：台中榮民總醫院 ( S04-34899F)
The patient is a 46-year-old man with the underlying history of nasopharyngeal
carcinoma, status post chemotherapy and radiotherapy.
He was regularly followed up in our ENT outpatient department. During regular CT
scan of lung in September, 2015, a renal mass at right upper pole was found. The
renal tumor measured 4.7 cm in size with heterogenous enhancement. Metastasis was
suspected as the first impression. Neither hematuria nor abdominal discomfort was
told. The patient had smoked 1.5 PPD for 30 years and quit for 2 years. His
occupation is 汽車烤漆 for 20 years.
Laparoscopic right nephrectomy was performed in November, 2015.
Case-13: 基隆長庚醫院
(Virtual)
A 71-year-old female presented with abdominal discomfort, recurrent post-voiding
retention sensation, urinary frequency, and dysuria with burning sensation for 8
months. Pelvic examination showed a partially fixed and dense cystic tumor with
indurated portions adhered to the vaginal cuff. Sonography showed a 14.0 x 7.5 cm
tumor with heterogeneous content and irregular contour. Computed topography (CT)
scan showed a pelvic tumor measuring 11.0 cm in greatest dimension, which appeared
to grow from left ovary. Laboratory data showed elevated levels of CA-125 (290.20
U/mL). She received abdominal total hysterectomy (possibly due to leiomyoma) 30
years ago. Left adnexectomy with omentectomy and excision of pelvic soft tissue
were performed.
Case-14：中國附設醫院 (2014-16122)(Virtual)
This 27-year-old woman without past medical history presented with a lung mass
accidentally found in chest X-ray study from routine health examination. Physical
examination showed no significant abnormality. Computer tomography showed
multiple lobulated lung mass, up to 4.7cm in diameter, in both lung. The largest
nodule locates in right upper lobe lung. All nodules had smooth margins.
Wedge resection of right upper lobe and right lower lobe lung mass are performed,
and was submitted as 2014-16122.
Case-15: 高醫附設醫院 (KMU-16-00680D2)
This 24-yer-old female presented with persistent right
nasal obstruction and right eye swelling for one
month. She was in her usual healthy state without
known systemic disease. She also denied any familial
hereditary disorder. There was no fever, purulent or
blood-tinged discharge, epistaxis or facial pain noted.
Fiberoptic nasopharyngoscopy showed right nasal
septum deviation and a mass in ethmoid sinus. Head
and neck CT scan showed a sinonasal tumor
involving right esthmoid sinus, maxillary sinus,
orbital bone and skull base (Fig1). Diagnostic
procedure (pan-sinusectomy) was done. The sections
submitted are taken from right ethmoid sinus.
(Fig1)
Case-16：台北榮民總醫院 (S101-11056) (Virtual)
This 52-year-old woman had total thyroidectomy for hyperthyroidism 20 years ago
and now under thyroxine treatment. She had nasal obstruction for 5-6 years and came
for help in 2012. A protruding mass, 4.2 x 2.8 x 3.8 cm, at nasal septum with
obstruction of bilateral nasal cavities is noted. The mass was hard and smooth in
character. She underwent tumor excision.
Case-17：高雄長庚醫院 (S2016-11152-2)
Without other relevant systemic diseases, this 4-month-old boy was
incidentally found to have a mass during inguinal herniorrhaphy and received biopsy.
Pelvic CT was arranged, revealing a 5.0 x 3.8 cm left inguinal mass with hydrocele
and several small inguinal lymph nodes. Radical excision of left inguinal mass with
lymph node sampling was performed.
Case-18：花蓮慈濟醫院 (S2011-12919A3)
Mrs. Lin, a 59 year old non-smoker and housewife, consulted to our hospital
in September 2011 with chief complaints of cough and hemoptysis for three months.
Her past history was remarkable for hypertension with medication for many years.
Besides, she had been suffering from right-sided intermittent chest pain that was
aggravated by coughing and relieved by right decubitus position for six months.
Apart from that, she denied night sweat, fever, change in body weight and appetite
change. The patient was moderately obese. Physical examination revealed dullness in
percussion and decreased breath sounds over right middle and lower lung fields. Right
massive pleural effusion and basal lung atelectasis were found by chest X-ray. Chest
computed tomography (CT) showed malignancy or abscess in right lower lung with
moderate pleural effusion. Effusion and sputum cytology were negative. CT-guided
biopsy showed interlacing spindle cells proliferation with inflammatory cells
infiltration suspicious of inflammatory myofibroblastic tumor. She underwent VATSassisted exploratory thoracotomy with right middle lobe (RML) and lower lobe (RLL)
bilobectomy via 6th intercostal space. Intraoperatively, huge RLL tumor about 12 cm.
in diameter that invaded into right superior and inferior pulmonary veins, RML
bronchus and RLL bronchus together with enlarged black lymph nodes at interlobar
and subcarinal regions were noted. The tumor was difficult to resect completely
because of the concern of narrowing the right superior pulmonary vein.
Eight months after operation, local recurrence was noted by chest CT. The tumor was
unresectable at that time of presentation. The patient received traditional Chinese
medicine. Her condition gradually progressed to complete bed rest due to dyspnea
even at rest, bilateral headache and dizziness. After two months, she was hospitalized
because of dysuria, nausea and vomiting. She was treated under impression of urinary
tract infection. The patient expired on admission day 2.
Case-19：彰化基督教醫院 (11616470A20)
The 24- year-old female presented with shortness of breath on exertion for 2 months.
According to the patient' statement, the symptom progressed with dry cough in recent
two months. She also noted persisted right chest wall tenderness. Image study reveals
huge soft tissue in the right upper thorax involving spine. Surgical intervention with
corpectomy of spine and wedge resection of right lower lobe lung was performed.
Case-20：三軍總醫院
This 25 y/o female had abdominal tenderness and poor appetite persisted for 3 days.
She had no systemic disease or operation history in the past. A homogenous mass size
9.2 x 5.9 cm in lower abdomen with invasion of ileum was seen after abdominal CT
examination. During exploratory laparotomy, the tumor lesion was near the lower
region of ligament of Treitz about 40 cm. Under the clinical impression, the
differential diagnoses included GIST (Gastrointestinal stromal tumor), lymphoma and
leiomyosarcoma.
Case-21：台北榮民總醫院
(virtual)
A 48-year-old woman presented to a local clinic after noting left side chest pain
and cough for 6 months. She did not have history of any medical or surgical illness.
Chest X ray showed osteolytic lesions in left upper lung field. Computed tomography
scan demonstrated two sclerotic expansile lesions in the left third rib. The patient was
referred to our hospital for further management.
After admission to our hospital, bone scan was performed, which showed two
foci of increased uptake in the left third rib. Contrast-enhanced magnetic resonance
imaging showed two fusiform expansile lesions in the left third rib, with
heterogeneous signal intensity on T1WI and T2WI and avid contrast enhancement.
The anterior lesion is about 8.0 cm in long axis, while the posterior one is about 2.0
cm. After discussion with the patient, wide excision of the rib lesions was performed.
Case-22：林口長庚醫院
A 36-year-old female without known medical history underwent panendoscopy
during routine health examination. A 2 cm, pedunculated polyp was found at the
mid-body of the stomach. The section was taken from the polypectomy specimen.
Case-23：台大醫院新竹分院 (Virtual)
This 10-year-old boy with the history of Tourette syndrome and cryptorchidism. He
complained left foot pain for 2 months and walked with antagic gait. The physical
examination showed local tenderness over left 4th metatarsal bone area, with
paresthesia, and hypersensitivity. The followed X-ray revealed no bony lesion and the
echo showed one soft tissue tumor, about 0.8x0.6x0.6cm in size. A morton's neuroma
was suspected clinically and excision was performed. However, severe pain with
recurrent tumor growth was noted 3 months later, and the followed MRI revealed a
hypervascular lesion nearby prior operative site. Re-excision was performed and the
histology was shown on virtual slide.
Case-24：國泰醫院 (Virtual)
This 78-year-old man denied any systemic diseases. He visited our clinic due to a
palpable mass at right knee popliteal area within several months. He had no local
tenderness, swelling or heat. Physical examination revealed a moveable and firm mass
about 1.6 cm in greatest diameter at subcutaneous area without skin eruption or
ulceration.
Case-A：台中榮民總醫院嘉義分院 (圖片)
This 20 years old man denied any systemic disease before. He complained about right
infraauricular mass for 1 year. The tumor was firm and mild tenderness when
palpation hardly. He went to our OPD, and a firm mass, 2x2 cm, over right
infraauricular region was noted. CT was arranged and showed a rim enhancing lesion
about 1.4cm is noted at superficial lobe of right parotid gland.
Cyto-B：台北榮民總醫院
(圖片)
This 36-year-old man presented with persistent cough for two months. Chest X-ray
and CT showed a large infiltrative mass involving LUL and LLL, with mediastinal
invasion, hilar and mediastinal lymphadenopathy, and pleural and pericardial effusion.
He underwent LUL wedge resection and the pathological diagnosis of the tumor was
poorly differentiated squamous cell carcinoma. Chemotherapy was given.
Pericardiocentesis was performed to relieve his orthopnea, and the pericardial fluid
was sent for cytology.
Case-C：嘉義基督教醫院 (圖片)
A 38 year-old lady had the medical histories of hypertension and hyperlipidemia,
under regular control at our nephrologic outpatient department. She complained of
persistent hoarseness for 3 months with intermittent chocking and mild dry cough.
She visited our ENT OPD for help where laryngoscope showed incomplete glottic
closure with right vocal paralysis. There was no vocal polyp or nodule. Neck
ultrasonography revealed right thyroid mass and fine needle aspiration was performed.
The cytology was suspicious for malignancy. Therefore, CT image was arranged and
showed right thyroid tumor with compression to trachea. She was admitted for
schedueled total thyroidectomy in Sep. 2015. The final pathology report is carcinoma
showing thymus-like differentiation.
Case-D：奇美醫院 (0105-09-0121) (圖片)
This 92 years old male patient has a history of chronic obstructive pulmonary disease
and pulmoanry TB infection status post anti-TBs treatment in 2014/08. According to
patent's family, he suffered from exertional dyspnea and poor appetite in recent 2
week. In addition, cough and fever were noted. Chest x-ray revealed pleural effusion
at right pleural cavity. Chronic obstructive pulmonary disease with acute exacerbation
induced by infection was impressed in admission. Laboratory tests for Mycoplasma
pneumonia, Chlamydia pneumonia, Influenza virus, were negative. MTB Quantitative
PCR shows no evidence of current TB infection. The attached PowerPoint file shows
representative photos of two cytologic examinations from pleural effusion.