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Special Feature |

Image of the Month—Quiz Case FREE

Joshua Wolf, MD; Hien Nguyen, MD; Jonathan Koehler, MD; Elliot Fishman, MD; Michael Marohn, DO
[+] Author Affiliations

Author Affiliations: Johns Hopkins University, Baltimore, Maryland.


SECTION EDITOR: CARL E. BREDENBERG, MD


Arch Surg. 2011;146(7):883-884. doi:10.1001/archsurg.2011.165-a.
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Published online

A 55-year-old morbidly obese man presented with recurrent lower back pain. Imaging with computed tomography showed a 6 × 6-cm hypervascular mass at the aortic bifurcation, immediately anterior to the iliac arteries, with a central area of focal necrosis (Figure 1). There was no radiological evidence of pelvic lymphadenopathy. Results of urine chemistry studies revealed mildly elevated catecholamine levels, with a norepinephrine level of 89 μg/g of creatinine (reference range, 7-65 μg/g of creatinine) and epinephrine, dopamine, and creatinine levels all within normal limits. The patient denied any history of episodic hypertension, dizziness, palpitations, headaches, or diaphoresis. He also denied any recent fevers, night sweats, or chills and had no history of cancer or irradiation therapy.

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Graphic Jump Location

Figure 1. Computed tomographic imaging of a large mass at the aortic bifurcation. Notable features include hypervascularity, large diameter, and central area of necrosis.

The patient was taken to the operating room, and the tumor was removed with hand-assisted laparoscopy. The gross specimen appeared tan and red, with a thin capsule encasing the tumor in its entirety. Histological analysis revealed a “patternless pattern” of mesenchymal cells with a high degree of vascularity and strands of collagen deposition (Figure 2). Immunohistological staining of the tumor specimen was strongly positive for CD34 and bcl-2.

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Graphic Jump Location

Figure 2. Histological section of the tumor with a “patternless pattern” of mesenchymal spindle cells, abundant vascular structures, and a collagen matrix, all typical features of solitary fibrous tumor (hematoxylin-eosin, original magnification ×40).

WHAT IS THE DIAGNOSIS?

A.  Paraganglioma (organ of Zuckerkandl)

B.  Lymphoma

C.  Retroperitoneal sarcoma

D.  Solitary fibrous tumor

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Computed tomographic imaging of a large mass at the aortic bifurcation. Notable features include hypervascularity, large diameter, and central area of necrosis.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Histological section of the tumor with a “patternless pattern” of mesenchymal spindle cells, abundant vascular structures, and a collagen matrix, all typical features of solitary fibrous tumor (hematoxylin-eosin, original magnification ×40).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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