(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 6 year old girl from Medellin, Colombia, South America, presented with twenty-five days of left-sided headache, vomiting, and episodes of syncope lasting roughly five seconds. The patient had no other medical history of significance. She had no café au lait spots, and no other tumors or masses in other body sites. Neurological examination revealed no focal deficits. An MRI scan showed a large intra-axial left parietal lobe mass with significant surrounding edema. The mass did not appear to originate from the dura; it did reach or breach the pia on the parietal convexity, and medially close to the falx. The falx was pushed by the mass effect of the tumor and was clearly separate from it. (Fig 1). A surgical excision was done in Colombia, and a tentative diagnosis made. The slides and selected blocks were sent to the University of Missouri for consultation. Since the time of surgery, the patient has been treated with radiation (thirty treatments) and has done extremely well. Neurologically she is almost completely normal, and her mother reports that the patient is asymptomatic and leading a normal life attending school.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 70-year-old man presented with a 10-month history of worsening cognition, speech impairment, ataxia, and dysphagia, as well as periodic episodes of brachial dystonia, choreiform movements, and facial grimacing. EEG studies were negative. MRI studies, including arterial spin labeling, showed only hyperperfusion of the right mesial temporal lobe. FDG-PET showed diffuse cortical hypometabolism (Figure 1A, white arrows) and relatively increased metabolism in the amygdala (Figure 1A, yellow arrows) and striatum (Figure 1A, orange arrow) bilaterally. Imaging studies of the chest, abdomen, and pelvis were negative. Despite therapy, the patient's disease proved refractory and he expired. A brain-only autopsy was performed 16 months following his initial presentation.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 70 year old former farmer and cattle breeder was admitted to a district hospital due to intermittent confusion, neuropsy-chological slowing with otherwise unremarkable neurological examination. His family first noticed personality changes after a right knee arthroscopy two weeks earlier.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

Male African-American patient in his 70s presented with a non-tender mass on the medial aspect of the distal third of the right thigh that had been present for several years and had recently increased in size.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 70 year-old male with a 55 pack/year cigarette smoking history, remote history of minimally invasive pancreatic adenocarcinoma, status post pancreaticoduodenectomy procedure in 2008, and superficially invasive esophageal adenocarcinoma diagnosed within the last month presented with multiple bilateral subcentimeter lung nodules, a prominent right upper lobe lung nodule, and a necrotic-appearing posterior mediastinal mass on a recent chest CT scan. A subsequent chest PET scan demonstrated increased uptake only in the posterior mediastinal mass. Fine Needle Aspiration (FNA) of the posterior mediastinal mass was attempted, but cytology was inconclusive.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient was a 70-year-old man who was diagnosed 8 years prior to death with prostate adenocarcinoma. He underwent a radical prostatectomy. Pathological examination showed Gleason sum score of 3 + 4 = 7 / 10 with positive surgical margins and extracapsular extension. Serum PSA remained elevated post-op. Despite androgen deprivation therapy, chemotherapy and radiotherapy the tumor progressed, manifesting primarily as bone metastases. He was placed on hospice care 6 months prior to death.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 70 year-old man presented with a 8 year history of cognitive decline. Initial presenting signs included mild memory loss, behavioural disturbances, and transient episodes of disorientation. Neurological examination revealed frontal release signs, including severe confusion, hallucinations and bilateral grasping, pyramidal signs, facial dyskinesia and dysmetria. During this first hospitalization, his "mini mental status" (MMS) was quoted as 25/30. Laboratory investigations showed undetectable ceruloplasmin in serum, increased ferritin (1777 µg/L - normal 30-300) and a slight decrease of serum iron (11,8µmol/l -normal 12-30) and copper (0.06 mg/l - normal 0.8-1.4) levels. Fundus oculi was normal; there was neither Kayser-Fleischer ring nor retinal abnormality. There were no signs of diabetes mellitus. Brain MRI revealed bilateral increased signal intensities of deep nuclei on T1 weighted that were more marked on T2 weighted sequences. The abnormalities involved predominantly the putamen, caudate nucleus, pulvinar, and dentate nucleus. Contrast infusion did not show any signal modification. (Figures 1 and 2). Due to a suspicion of hemochromatosis, a liver biopsy was performed. It showed normal liver architecture, absence of cirrhosis and marked iron deposition. Aspirated bone marrow showed normal cytology and cellular count but massive iron deposition.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 71 year old man presented with a two-day history of periodic severe left-sided occipital headache, blurry vision, alexia without agraphia, and occasional nausea without vomiting. His past medical history is significant for hypertension, for which he takes lisinopril, hydrochlorothiazide, and verapamil. He also takes meloxicam for arthritis and pantoprazole for gastroesophageal reflux. He has no personal history of malignancy, but does have a family history significant for esophageal cancer. He does not smoke or use alcohol or drugs, and has no known environmental exposures. Physical examination was remarkable only for a right visual field deficit. Magnetic resonance imaging (MRI) showed a 5.2 x 4.6 x 4.0 cm area of complex signal abnormality in the left occipital/posterior parietal region, with some cortical effacement and white matter edema, but no significant mass effect (T2-weighted MRI; Figure 1). All sequences showed serpiginous and punctate foci of low signal, suggestive of hypervascularity, but revealed no large feeding or draining vessels. There was no diffusion restriction. Irregular contrast enhancement involved a 4.3 x 3.8 x 3.2 cm region of the abnormality (T1-weighted post-gadolinium MRI; Figure 2). Computed tomography (CT) revealed an associated area of calcification near the sagittal sinus. For definitive diagnosis, a stereotactic left occipital brain biopsy was performed.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 71-year-old female presented to the emergency room with intermittent headache and several months of right eye proptosis. She had noticed some decrease in visual acuity for which she had been seeing an eye doctor. She denied blurry or double vision, focal weakness, bowel or bladder incontinence, numbness, tingling, fevers, chills, or difficulty swallowing. In retrospect, she admitted to right ear pain many years prior to presentation. A CT scan was performed which revealed an intracranial and temporal mass located on the right lateral orbital wall, abutting her optic nerve with features of osteoblastic activity (Figure 1). Head CT scan with bone windows shows expansion of the bone (Figures 1- axial, 2- sagittal, 3, 4- coronal views). The arrows in Figure 4 point to the contents of the orbit being compressed compared to the normal side. An MRI showed an avidly enhancing mass on T1 pre- (Figure 5) and post-contrast (Figure 6) images without dural involvement. The patient was consented for pterional craniotomy and resection of this unknown bone lesion.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

GROSS AND MICROSCOPIC DESCRIPTIONS:

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient was a 71 year old male with a history of diabetes and coronary artery disease who presented to the emergency department with recent progressive constipation, black stools, and cramping abdominal pain. A CT scan revealed an obstruction in the transverse colon suspicious for a mass, but no overt evidence of metastatic disease was identified. A colonoscopy was then performed, which confirmed the radiologic impression. The patient ultimately underwent a right hemicolectomy and the resection specimen was submitted for pathologic evaluation.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

Past medical history is significant for seminoma in 1999 with orchectomy and chemotherapy complicated by peripheral neuropathy. He was "told he had a recurrence" in 2002, with unclear follow-up. The patient had not received adjuvant therapy in three years prior to presentation. In addition, the patient had deep venous thrombosis with pulmonary embolism with pulmonary thrombectomy, lifelong Coumadin prophylaxis, and Greenfield filter placement in the inferior vena cava. Mild chronic renal insufficiency was also noted. He has a 60 pack-year history of smoking.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 71 year old man underwent a radical orchiectomy for a left solid testicular mass.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 71-year-old female had been well until approximately 2 years before admission, when a neurologist noted muscle rigidity, decreased arm swing while walking, mask-like face, pill rolling tremor and some difficulty in writing. Levodopa/carbidopa (up to 200mg/day) was not effective and was withheld because of exacerbation of tingling sensation of the lower extremities. Four months before admission, she complained of visual hallucinations of children or objects. Endoscopic examination identified a gastric ulcer as a cause of melena and anemia, which lead her to this admission.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 72-year-old woman presented with a 4-year clinical history of increasing confusion, memory loss, depression, and dizziness. Neuroimaging studies including CT and MRI showed bifrontal dural masses (Figure 1a) and a right-sided tentorial mass in the cerebello-pontine angle (Figure 1b). The supratentorial masses were considered suspicious for multiple meningiomas or CNS lymphoma, whereas schwannoma was favored for the cerebello-pontine angle mass. Microsurgical resection was performed of the both frontal lesions and right cerebello-pontine mass. After the pathological diagnosis was rendered, systemic lesions were detected by PET in the humerus and femur, piriform sinus, ilium, clavicles and mandible (Figure 1c). The patient underwent a course of vemurafenib treatment, a BRAF-inhibitor, which improved the neurological status.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 72-year-old woman presented with progressively hearing loss over past ten years and recently developed pain in her left ear and face. The patient had a history of migraine for most of her adult life. On physical examination, facial muscle and sensation were symmetric and hearing was intact to finger rub bilaterally. Subsequent MRI revealed an enhancing mass measuring 2.6 x 1.6 x 2.1 cm within the left lateral ventricular atrium (Figure 1a), compatible with intraventricular meningioma. There was increased perfusion and blood volume within the mass and surrounding confluent T2 hyperintensities suggestive of vasogenic edema (Figure 1b). She underwent a craniotomy and tumor excision. During surgery, it was noted that the tumor was rising off the choroid plexus. A biopsy of the mass was submitted for intra-operative consultation. Following examination of the smear and frozen section, a debulking procedure was undertaken.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 72-year-old male initially presented to the neurosurgical service in 2004 with severe headache, seizure and gait instability. The scan demonstrated a pineal space occupying lesion and associated hydrocephalus. An endoscopic third ventriculostomy (ETV) and attempted tumor biopsy was performed, but it was non-diagnostic. Thereafter, he was followed both clinically and radiologically for three years before he was lost to follow-up. During the three years that the patient was followed, the lesion was asymptomatic and showed little increase in size on repeated MRI studies. Eleven years after initial treatment, he was readmitted to the hospital with approximately three-month history of significant gait slowing and instability in addition to intermittent blurred vision. He developed worsening memory along with poor concentration and attention. Many of these symptoms were similar to the episode he experienced prior to his ETV. The CT scan performed on admission demonstrated a pineal region hyperdense lesion (3.7 x 3.3 x 3.6 cm) causing compression of the quadrigeminal plate with effacement of the cerebral aqueduct and quadrigeminal cistern and significant mass effect on the cerebellar vermis (Fig. 1). MRI scans showed a heterogeneously enhancing pineal region lesion causing mass effect on the midbrain, cerebellum and splenium of the corpus callosum. No hydrocephalus was noted. He underwent an infratentorial supracerebellar approach and subtotal resection of tumor.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 72 year old female with no significant past medical history who was under treatment and follow up for her chronic low back pain was referred to our center for evaluation of an incidentally discovered intramedullary lesion in her thoracic spine after her recent fall. She didn't have any neurologic deficits at the time, including weakness or any bladder or bowl dysfunction and on exam she was neurologically intact. On her further work up, MRI of thoracic spine revealed a well-defined intramedullary lesion with an intradural component measuring about 1 cm at the level of T10. (Fig 1, left) There was a mildly increased T2 signal with enhancement after gadolinium administration. Chronic superior endplate compression fracture of T9 and L1 vertebral body was also noted. The intramedullary lesion was considered an incidental finding unrelated to her symptoms therefore the initial plan was close observation, given her unwillingness for any surgical intervention, in addition to the small size of the lesion, lack of neurological deficits and its benign appearance on imaging. Based on imaging, the differential was a low-grade astrocytoma, ependymoma or an intramedullary schwannoma. After about 3 years, in a follow up visit, we noticed a mild weakness in her left lower extremity and some gait unsteadiness. This was accompanied by a significant increase in the size of the lesion (Fig 1, right), so she agreed to an excisional biopsy. Intraoperatively the lesion was noted to be a bluish, firm mass with a good plane at the level of T10/11.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

The patient is a 72 year old man who presents for evaluation of elevated serum PSA (Prostate Specific Antigen). His most recent PSA was 10.1 ng/ml, and he has a history of PSA <1 ng/ml (4 years ago=0.77 ng/ml, 2 years ago=0.7 ng/ml). He has no signs or symptoms of prostate enlargement, including nocturia, changes in voiding, or daytime frequency. He denies prior urologic surgery. The patient does have a family history of prostate cancer, with his brother being diagnosed at age 72.

(This case study was added to OER Commons as one of a batch of over 700. It has relevant information which may include medical imagery, lab results, and history where relevant. A link to the final diagnosis can be found at the end of the case study for review. The first paragraph of the case study -- typically, but not always the clinical presentation -- is provided below.)

A 72-year-old man presented abruptly with a grand mal seizure while he was dancing. He was admitted to our hospital and physical examination detected mild left upper limb paresis. His medical history included idiopathic hypertension and non insulin-dependent diabetes, both under specific drug therapy. Cranial magnetic resonance imaging (MRI) revealed a 4 x 4 x 3-cm extraaxial lesion, isointense on T1-weighted images and hyperintense on T2-weighted images, with heterogenous enhancing. It was located in the posterior right frontal convexity with poorly defined boundaries and remarkable perilesional edema (Fig. 1). The patient then underwent total microsurgical resection of the hypervascular intracranial mass. During operation, the tumor was found to be a mass partially encapsulated with dural attachment. The surgical appearance was felt to be atypical for meningioma. The dissection showed a prominent and arterialized venous drainage and no evident cleavage plane in some areas. A small piece of tumor was submitted for frozen section (Fig. 2).