Extranodal Rosai-Dorfman Disease Presenting as a Pancreatic Mass Associated With Superior Mesenteric Artery Thrombosis

ACG Case Reports Journal · 2026-03-01

Rosai-Dorfman disease (RDD) is a rare, nonmalignant histiocytic disease that classically presents as bulky lymphadenopathy. Although RDD can be seen in various organ systems, gastrointestinal involvement is uncommon. We present a case of RDD involving the pancreatic head causing biliary obstruction, arterial thrombus, abdominal pain, and concern for malignancy. Endoscopic ultrasound and pancreas biopsy demonstrated a mass without malignant features and pathological features including benign pancreatic parenchyma, noncaseating granulomas, and mixed acute and chronic inflammation including histiocytes with emperipolesis and a staining pattern that confirmed a diagnosis of RDD. She experienced symptom relief and reduced mass size and metabolic activity after treatment with cobimetinib. When there is uncertainty surrounding the etiology of a slow-growing pancreatic mass with atypical features, the differential diagnosis should include uncommon causes such as RDD and may warrant evaluation in a tertiary referral center to avoid extensive and unnecessary surgery.

Unruptured Giant Internal Carotid Artery Aneurysm Compressing the Pituitary Gland Leading to Panhypopituitarism

AACE Endocrinology and Diabetes · 2025-10-01

Background/Objective: Internal carotid artery aneurysms are rare and can lead to hypopituitarism due to their mass effect. Hypopituitarism triggered by aneurysmal compression may persist, and postsurgical restoration of pituitary function is challenging, often necessitating long-term hormone replacement therapy. We herein report a case of hypopituitarism caused by intrasellar aneurysm. Case Report: A 77-year-old female with history of left eye blindness, Hashimoto's thyroiditis, and chronic kidney disease presented with nausea, vomiting, malaise, and altered mental status. Physical examination was unremarkable with no visual field or neurologic deficits except for blindness in left eye. The patient was noted to have hyponatremia which prompted checking serum cortisol level and endocrinology consultation. Workup demonstrated secondary adrenal insufficiency with low cortisol and low adrenocorticotropic hormone, central hypogonadism, and secondary hypothyroidism with low serum thyroid-stimulating hormone and low free thyroxine level. Prolactin was mildly elevated, likely due to stalk effect. Imaging revealed 2.3 × 3.1 × 2.3 cm right cavernous carotid aneurysm in the sella extending into the suprasellar cistern. Hydrocortisone therapy was started, and levothyroxine dose was adjusted which improved her mental status. Subsequently, the patient underwent stent-assisted coil embolization after unsuccessful placement of a flow diversion device by neurosurgery. The patient continues to be on hormone replacement therapy. Discussion/Conclusion: Close monitoring of pituitary hormones is required in the context of giant intrasellar aneurysms, given their potential to induce pituitary dysfunction through mass effect. Timely diagnosis and intervention are paramount to prevent fatal outcomes.

Reviewers for the College of American Pathologists 2022 Annual Meeting (CAP22) Abstract Program

Archives of Pathology & Laboratory Medicine · 2022-08-31 · 1 citations

Primary hepatic neoplasms arising in cirrhotic livers can have a variable spectrum of neuroendocrine differentiation

Human Pathology · 2021-07-24 · 9 citations

Evaluation of pelvic washing specimens in patients with endometrial cancer: Cytomorphological features, diagnostic agreement, and pathologist experience

Cancer Cytopathology · 2021 · 13 citations

• Medicine
• Radiology
• Pathology

BACKGROUND: Pelvic washings for patients with endometrial cancer is recommended but not used for staging. The International System for Reporting Serous Fluid Cytology (TIS) has standardized diagnostic categories, but the criteria remain incomplete. The 3 primary goals of this study were to 1) investigate features that distinguish atypical/indeterminate from malignant specimens, 2) measure the level of agreement between chart and reviewer diagnoses, and 3) determine whether the number of years in practice had an effect on the diagnoses rendered. METHODS: Pelvic washings and surgical pathology specimens for 52 patients with a chart diagnosis of atypical/indeterminate, suspicious, or malignant cytology and 52 age-matched controls with a negative chart diagnosis were included, reviewed blindly by 2 cytopathologists, and assigned a study diagnosis. Morphologic features were assessed. Agreement between original chart diagnoses and reviewer diagnoses were assessed as well as effect of years in practice. RESULTS: The overall cellularity in cell block (CB) slides for the malignant category was significantly increased compared with the atypical/indeterminate category (P < .0001). In addition, the number of atypical groups in ThinPrep for malignant washings was significantly increased compared with the atypical category (P < .001) and the negative and suspicious categories (P < .0001) in the CB. Overall agreement between the original and adjudicated diagnoses was high (γ = 0.983). There was no significant difference between diagnoses rendered and years in practice. CONCLUSION: The overall cellularity and number of atypical cells can be used to distinguish between malignant and atypical pelvic washing specimens. There is high reproducibility in the diagnostic categories and high agreement among pathologists, regardless of practice experience. These findings can help refine the criteria for TIS.

Change in Pathology Medical Education: The Time Is Now

Archives of Pathology & Laboratory Medicine · 2021-08-30 · 2 citations

Change happens when something becomes different, altered, or transformed. There are very few circumstances in life in which change is received welcomingly, such as the birth of a baby. Change frequently makes us uncomfortable. Change is difficult. No one really wants to change. The status quo works. Despite our aversion to change, change happens with or without our consent. Standard operating procedures change in our laboratories. A new laboratory information system is adopted. Accreditation standards are amended, and we must comply.Like a steam locomotive roaring down the tracks, the events of 2020 brought into clear focus the concept of change. Both our personal and professional lives were suddenly filled with unavoidable change. We were on lockdown in our homes adapting to virtual learning while we hastily implemented telepathology using online meeting platforms for virtual sign-out, consensus conference, and tumor boards. We dedicated laboratories to detection of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We acquired and validated new testing platforms. We learned far more than we ever wanted to know about the supply chain. Simultaneously, we witnessed, and possibly experienced, human suffering: illness, hunger, financial uncertainty, death, and racial injustice.In the wake of change, we pick up the pieces, reassemble them, and make the new status quo work for us. But it is not easy; it is a process. Response to change, or the change curve, is somewhat predictable and interestingly parallels the 5 stages of grief described by Kübler-Ross1 in On Death and Dying. Although the stages are sequentially numbered, an individual's experience may be nonlinear or even become stuck in one phase for an extended period of time, both of which are normal. Change, at first, is often met with shock, denial, and frustration and provides us an opportunity to process the news of change. Think about how you reacted when you were told that major workflow changes or a new laboratory information system was imminent. Although denial is frequently short-lived, it is possible to get stuck, refusing to accept the impending change. Anger is the second phase. Anger could be directed at oneself, the change, or the change agents. Bargaining, the third phase, allows us to avoid the change, for example by potentially negotiating a lesser change. The fourth stage is depression, in which we may be overcome by negative emotions such as sadness, fear, and regret. With time we realize that change is inevitable and come to the fifth stage, acceptance. We then decide to learn how to work with the new situation, which results in a more positive feeling. Eventually, change is integrated, and it is difficult to recall how things were prior to the change.As leaders, we know that change provides us with an opportunity to create a vision of how things ought to be and then work to bring that vision to reality. We can use the knowledge of the change curve to assist with the change process by providing information, support, and resources as needed as we usher in change.Medical education is a rapidly evolving field, presenting many opportunities for change that affect all learners, including medical students, residents, fellows, and practicing pathologists. In this special section on medical education, 4 articles are presented, drawing on important themes in medical education: diversity/inclusion/equity, well-being, teaching pathology, and continuing certification. Although the stage had been set for change prepandemic, the pandemic magnified the need for change. These opportunities for change have become increasingly important, and we can ill afford to ignore them.The events of 2020 raised awareness of social injustice and inequality and helped many white people to finally see and recognize the privilege they enjoy in a society based solely on their outward appearance. The concept of structural racism has reached the fore, and some have begun to look at facets of society through the lens of structural racism to understand how it impacts all of us. The house of medicine, including pathology, has not been immune to structural racism.2 Thankfully, some are beginning to take critical looks at systems to identify opportunities for improvement. In “Strategies to Enhance Diversity, Equity, and Inclusion in Pathology Training Programs: A Comprehensive Review of the Literature,” Ware, Flax, and White provide us with an opportunity to rethink residency recruiting. With a focus on the pathology pipeline and recruitment of those underrepresented in medicine in pathology training programs, Ware, Flax, and White present strategies for enhancing diversity, inclusion, and equity in pathology through the residency recruiting process.The expert lecturing at a podium style of teaching is outdated and no longer meets the needs of modern learners. In “Medical Education in Pathology: General Concepts and Strategies for Implementation,” Koch, Chang, and Dintzis present high-yield educational tactics relevant to pathology that may enhance teaching and learning in medical school, residency, and fellowship. The pandemic forced us to rapidly embrace change to use technology in medical education3 so that education could continue during the pandemic while allowing for physical distancing.4 Suddenly we became adept at using online meeting platforms not just for meetings, but also for livestreaming surgical pathology sign-out and frozen sections, and, of course, for delivering educational content such as the College of American Pathologists virtual pathology lecture series5 and annual meetings. As we begin to consider postpandemic educational delivery, we have an opportunity to reconsider how we teach medical students, residents, fellows, our pathology colleagues, and our nonpathology colleagues. In doing so, we should identify educational successes during the pandemic that may be relevant in a postpandemic learning setting that combines the key concepts in education presented by Koch, Chang, and Dintzis with technology to provide active, engaging learning for all.In “The American Board of Pathology's 2020 Continuing Certification Program,” Johnson provides need-to-know information for all diplomates, especially those participating in the Continuing Certification (CC) program. Although the article provides an update on CC program requirements beginning in 2021, it simultaneously details a change narrative. As the American Board of Pathology has implemented the CC program, it has been responsive to the needs of many stakeholders and has adapted the program to ensure all stakeholders' needs are met.If well-being was not top of mind prepandemic, it cannot be avoided now. The daily pandemic grind superimposed with the steady news stream of human suffering is difficult. Now is the time to take stock and ensure that well-being is meaningfully considered and addressed in your practice. Well-being science at once provides us an opportunity to change and is an effective antidote to our aversion to change. Sexton, Adair, and Rehder present “The Science of Health Care Worker Burnout: Assessing and Improving Health Care Worker Well-Being.” In this article, they provide us a common language for understanding burnout, resilience, and well-being, tools for measuring and assessing burnout, and easy to use evidence-based techniques for improving well-being at both the organizational and individual levels.As leaders in our organizations and practices, it is our collective responsibility to lead the necessary wave of change in medical education. It is true that change is difficult. Change reminds us of our spheres of control and lack thereof. We can use this knowledge to reframe change. It is up to us to identify the positives and shape change for the better. We have an opportunity to combine creative teaching techniques with technology to engage all learners: medical students, residents/fellows, pathologists, and our physician colleagues. We must incorporate well-being and diversity/inclusion/equity principles into our local contexts. The time for change is now.

Endometrial Adenocarcinomas With No Specific Molecular Profile: Morphologic Features and Molecular Alterations of “Copy-number Low” Tumors

International Journal of Gynecological Pathology · 2021 · 7 citations

• Pathology
• Biology
• Medicine

The study evaluated morphologic patterns, mutational profiles, and β-catenin immunohistochemistry (IHC) in copy-number low (CNL) endometrial adenocarcinomas (EAs). CNL EAs (n=19) with next-generation or whole genome sequencing results and available tissue for IHC were identified from our institutional database. Clinical data and histologic slides were reviewed. IHC for β-catenin was performed and correlated with mutation status. Images of digital slides of CNL EAs from The Cancer Genome Atlas (TCGA) database (n=90) were blindly reviewed by 4 pathologists, and morphology was correlated with mutation status. Categorical variables were analyzed using the Fisher exact test, and agreement was assessed using Fleiss κ. CTNNB1 mutations were present in 63% (12/19) of CNL EAs. β-catenin nuclear localization was present in 83% of CTNNB1-mutated tumors (10/12) and in 0% (0/7) of CTNNB1-wildtype tumors (sensitivity 0.83, specificity 1.00). Squamous differentiation (SD) was present in 47% (9/19) and was more often observed in CTNNB1-mutated tumors (P=0.02). Mucinous differentiation (MD) was associated with KRAS mutations (P<0.01). Digital image review of TCGA CNL EAs revealed that pathologist agreement on SD was strong (κ=0.82), whereas agreement on MD was weak (κ=0.48). Pathologists identified SD in 22% (20/90), which was significantly associated with the presence of CTNNB1 mutations (P<0.01). CNL EAs demonstrate several morphologies with divergent molecular profiles. SD was significantly associated with CTNNB1 mutations and nuclear localization of β-catenin in these tumors. Nuclear expression of β-catenin is a sensitive and specific IHC marker for CTNNB1 mutations in CNL EAs. CNL EAs with KRAS mutations often displayed MD.

Obesity Is Associated With Worse Overall Survival in Women With Low-Grade Papillary Serous Epithelial Ovarian Cancer

UNC Libraries · 2020-11-03

To evaluate prognostic risk factors for survival in women with low grade serous epithelial ovarian cancer (LGSC).

The association between progesterone receptor expression and survival in women with adult granulosa cell tumors

Gynecologic Oncology · 2019-01-18 · 9 citations

Emerging From the Basement: The Visible Pathologist

Archives of Pathology & Laboratory Medicine · 2019-07-24 · 10 citations

There is a perception that US medical school graduates' (USMGs) interest in pathology is waning. This concern, in an era of projected physician and pathologist shortages,1,2 has implications for the delivery of quality patient care to an aging population. Given this, can we increase interest in our field?Data from the National Residency Match Program reveal a steady decline in the percentage of first-year pathology positions filled by graduating medical students from allopathic schools since 1978.3 During that same time span, the percentage of total graduating US allopathic seniors selecting pathology as their specialty fluctuated cyclically. In 1979, 2.16% (282 of 13 036) of students selected pathology, whereas 0.88% (128 of 14 610) did so in 1998. By 2005, 2.21% (326 of 14 719) selected pathology, with the percentage falling to 1.17% (220 of 18 818) by 2018. Although the percentage of total positions filled by USMGs has decreased since 1978, the actual ratio of USMGs choosing pathology compared with the total number graduating has only mildly fluctuated. Therefore, the outlook may not be as bleak as once suspected; however, the drive for increased interest in our field should remain a goal.To increase interest in pathology, we must focus on visibility within both medicine and popular culture. Medical students think of pathology as a clinically invisible specialty and are unaware of it, forget about it, or ignore it as a career path.4,5 Therefore, students are not rejecting pathology; it simply is not included in their slate of career options. Pathology is not a required clerkship in most American medical schools, which limits students' exposure to the role that pathologists play in patient care. If students complete elective pathology clerkships, they typically do so during the fourth year of medical school, when career path changes seldom occur. Recent changes in undergraduate medical education could also be leading to a poor understanding of the clinical practice of pathology. After the release of the Carnegie Report in 2010, many medical schools changed curriculum delivery from a traditional subject-based approach with multiweek pathology courses to a systems-based approach with integration of subjects.6 This more fragmented view of pathology may lack sufficient exposure and leads students to believe pathologists are basic scientists with limited career options.4,7,8 Moreover, when students are aware of pathologists their perceptions are limited to unflattering stereotypes perpetuated in medicine and the media.Stereotypically, the depiction of pathologists on television has usually been restricted to autopsy and forensic pathology. Furthermore, it is unclear that those characters are physicians or they are forced to do autopsies because they are incompetent physicians. Negative portrayals of pathologists are difficult to counter in the media. Good role models in pathology, such as Bennet Omalu, MD, and his work with concussions and chronic traumatic encephalopathy, need highlighting to balance the more negative stereotypes and expose the public to the clinical practice of pathology.Where to go from here? When looking at the data from low power, there may be less of an issue in the number of US students applying for pathology than perceived; however, the issue of visibility remains an opportunity. A better understanding of the central role pathology has in health care will lead to improvements in interdepartmental working relationships, proper use of laboratory services, and the delivery of patient care. Adding “what is the practice of pathology” lectures into the core curriculum of medical schools or giving tours of the clinical laboratory as done at the University of California, Los Angeles (UCLA)9 can give medical students early exposure to the clinical practice of pathology. Student observation of multidisciplinary conferences and tumor boards can demonstrate the role pathologists play in the overall patient care system. Providing more opportunities for pathology electives in the third year of medical school can assist recruitment efforts while also teaching proper use of pathology services for those choosing other specialties. Many schools have established pathology student interest groups to increase interaction with pathology attendings and residents. Hands-on teaching activities, such as a fine-needle aspiration workshop with phantoms or a brain cutting demonstration, can leave lasting impressions with students. Furthermore, the pathology pipeline need not begin in medical school. Shadowing opportunities for high school and premedical undergraduate students can showcase a “day in the life” of a pathologist.Although traditionally a pathologist's patients are in the forms of microscopic slides and tubes of blood, many pathologists have patient-facing practices as well. Apheresis, fine-needle aspiration, and coagulation clinics are common ways that pathologists interact directly with patients. Increasing the visibility of pathologists beyond these roles has been a growing movement. Adam Booth, MD, Lija Joseph, MD, and colleagues have shown that patients have a desire to meet directly with their pathologist face-to-face and discuss their diagnosis to help them “see the dragon they are slaying.”10 Gibson et al11 have discussed the establishment of Pathology Explanation Clinics to address this same need. Uthman12 has written about the benefit of pathologists getting out from behind the “paraffin curtain,” interacting with other clinicians and becoming a visible part of the hospital system. This side of pathology should be visible to both our students and our colleagues to highlight pathologists as both the “doctor's doctor” and the “patient's doctor.”Pathologists are also interacting with patients and learners through social media, such as Twitter (San Francisco, California) and Facebook (Menlo Park, California). To dispel any concerns about Health Insurance Portability and Accountability Act of 1996 (HIPAA) violations, the posting of deidentified pathology photos to social media has been shown to be both legal and ethical,13 and academic pathology departments, state pathology societies, national pathology societies, pathology journals, and individual pathologists have become increasingly present on social media. Jerad Gardner, MD, an early adopter, has demonstrated the power of social media and how his interactions with the angiosarcoma patient support group on Facebook positively impacted both the patients and himself.14 Dr Gardner also has had great success in discussing interesting cases through Twitter and other social media platforms. In addition to increasing pathologists' visibility, social media can be harnessed to engage high school students, such as the Twitter account @pathoutprogram that “empowers and engages high school students to learn about pathology.”Pathology is a wonderful field with innumerable opportunities. The more we as a pathology community make ourselves visible to medical students, patients, and society, the better the outlook for our field and patient care into the future.