1. History
58 year-old female presented with back pain and right toe numbness.
Her past medical history was significant for hypertension, glaucoma and morbid obesity
Her past surgical history was significant for remote cholecystectomy
After outpatient evaluation by neurosurgery, an MRI of her spine was obtained

2. Describe the findings on the MRI imaging

3. Answer:
Destructive soft tissue mass centered at the lamina and spinous process of L5 which appears to measure in aggregate x 3.6 x 3 cm.
The patient was scheduled for a biopsy

4. Describe this low-power view from the smear preparation.

5. Answer Tissue fragments and small clumps of cells
Cellular smear
Tissue fragments and small clumps of cells
Specimen appears lesional

6. Describe the high-power cytologic features from the smear

7. Answer Acinar formation Abundant eosinophilic cytoplasm
Cohesive cells clusters
Intra-nuclear inclusions

8. Question:
Is the lesional tissue neoplastic?

9. Answer
Yes; and most likely a metastatic neoplasm. However due to the lack of any known primary tumor in this patient a final diagnosis can only be made on the permanent sections.

10. Question 2:
What other stains would be useful to make an accurate diagnosis of this lesion?

11. Describe the histologic findings on the permanent H&E section

12. Answer
Vaguely nodular and cellular lesion

13. Describe this high-power area

14. Answer: Similar to the smear preparation:
Cells forming acini-pseudoglands
Abundant granular eosinophilic cytoplasm
Round nuclei with coarse chromatin
Intranuclear inclusions

15. Describe this other H&E high-power field

16. Answer
This field shows marked steatosis in many of the neoplastic cells

17. By this time we are informed that her AFP level was 13422 ng/mL (normal range is <20)

18. Question
Based on the morphologic features and clinical presentation, what is the most likely diagnosis?

19. Answer
Metastatic hepatocellular carcinoma (HCC)

20. Question:
What stains would you do to confirm metastatic HCC

21. Answer HCC typically have this immunoprofile CK7 – CK20 – HepPar +
AFP +
A1-antitrypsin +
CEA +

22. Immunohistochemical stains
CK7
CK20

23. A1-AT
AFP
CEA
HepPar1

24. Are you convinced?
YES!