All good things must come to an end - Week 4

Well- last week in Kenya...an amazing experience for certain.

In the Hospital
Answer for last week's gross picture:
14 year old girl with a 1700g well-encapsulated mass deforming her breast.

The majority of the specimen has this pattern - TLDU with paucicellular, fibrous stroma.

Hyperplastic area with degenerative changes.  There was an area of infarction in the center of the mass.

Rare area with increased stromal cellularity.  (There is no atypia in the stroma and the epithelial component is not in a "leaf-like pattern".)

The tissue looks almost like normal breast, except for a small area of hyperplasia of terminal duct lobular units and the absence of adipose tissue.  We finalized the case as fibroadenoma. Great for the patient!  She had reconstructive surgery at the time of the excision.

Gross case of the week...with answer at the end of this post

This is an 8 cm parotid mass with linear calcifications in a background of vaguely nodular tissue with prominent vasculature.

Outside of the Hospital

Crafts

Fruit by the side of the road. Speed bumps on the highway are another great place to get fruit...without even having to get out of your car!

We saw approximately 10 rhinos at the Ol'Pejeta game reserve.  Docile creatures.

Farewell Lunch

Penina (third from the right) came over and cooked us my farewell/Ginger's welcome lunch.  She made ugali (a polenta the size of a large casserole), beef stew, and sukuma wiki (the greens).  It was so delicious.  Thank you to all who made this a wonderful rotation that I shall never forget!

Answer to this week's gross:

Carcinoma, most consistent with myoepithelial carcinoma. Angioinvasion and possible capsular invasion are present. 


See you in Seattle...Angelica

Time for reflection...-Week 3

This week has brought a lot of time for reflection.  I am so grateful to be visiting such a wonderful country, full of incredible wild-life and warm, generous people.  In the hospital, I am reminded how lucky I am to be healthy (exemplified by the gross case at the end).

In the Hospital 
Answer to last week's toe case:

Think of what your diagnosis for the first set of images.

We were originally going to sign this out as a malignant spindle cell neoplasm, strongly favor malignant melanoma since we do not have IHC available.  (The differential in this anatomic location is melanoma>melanoma>melanoma>>>>sarcoma). Until we saw this:

Melanoma in situ at one edge...we called it invasive melanoma.  No sentinel node available here, or BRAF and other special tests, so patient will be followed.

A Great Gyn Example
This specimen is from a 44 year old woman's uterine evacuation:

Trophoblasts are scary

All the villi look edematous and there are cystic structures appreciated grossly.  Marked non-polarized trophoblast proliferation.  Diagnosis is complete hydatidiform molar gestation.

Outside of the hospital:
This week brought Mount Kenya: plants and animal straight out of Dr. Seuss, a glorious sunrise, but most importantly a special guest: Dr. Mara Rendi, from the great state of Minnesota.

Gross Image of the Week:

Sadly, this is a breast mass from a 15 year old girl who lives in the slums of Nairobi.  The mass weighs 1700g and deforms her right breast, which hangs at her waist.  She was able to come to this hospital after scraping some money together.  The histology on the biopsy was called fibroadenoma. 

Until next time...Angelica

Week of Consults and Tumor Board - Week 2

Wow! Another amazing week has passed.
This week we got some usual cases.

First a BST case: 
Clinical history: 56 yo woman with a 2 year history of progressively enlarging mass on left scapula, associated with reduced range of motion and weight loss.  Appears lytic on imaging.

This is a sarcoma with epithelioid features and the differential diagnosis includes epithelioid sarcoma, epithelioid hemangoendothelioma and epithelioid neural neoplasm.  IHC is not available here, since the patients have to pay for it up front and then it is send out to Nairobi. Thank you to the BST team for the virtual consult.

A head and neck case:

Images first, then clinical history:

Clinical history: This is a 58 year old woman with a 35 year history of a neck mass resected twice previously elsewhere. She represents with a 5 cm lesion (below) at the previous resection site and the above polypoid squamous mucosa.

Did your thinking about the first set of images changed based on the second set? The first set of images evokes squamous cell carcinoma in situ, however note that although the nuclei are rather enlarged, the cytoplasm is AMPLE. There is no invasion. We think that this patient may have had radiation for ameloblastoma seen in the second set of images (which may explain the atypical mitoses).  The patient was discussed in tumor board and she has a small recurrence in a "tricky spot" according to her surgeon, but hopefully she will be able to be rid of this "benign" neoplasm that has resulted in a hemimandibulectomy.

Outside of the hospital:
We climbed Mt. Longonot this weekend - in the heat. I was very excited to get back to the starting point.

At the "summit", the highest point around the crater.

We were greeted by giraffes on our return to the base of the mountain.

Acacia tree with bulbs at the base of long thorns, where the ants await to attack giraffes.

Closer to home:

We were out on a short hike and passed a farm that sells "sukuma wiki", a green which is very popular here. Dr. Garcia is making sure that I have sufficient iron stores. 

We were joined by the local pathologist, Rosemary!

Answer to last week's gross case:

The middle of the first picture had a smooth, off-white nodule in the center corresponding to this focus of cartilage.

The center of the second picture had a soft "brainy" looking bit, immature neural tissue.

The important lesson for me was that this was a LARGE tumor (~20 cm). The first 6 slides submitted had only mature neural tissue!  Dr. Garcia went back and resampled, another 8 cassettes, and the majority had some immature component.  Large teratomas are almost always immature!

New gross case:

Clinical history: 56 year old woman with a progressive fungating mass on dorsum toe of left hallux fossa for one year.

This was grossed today, so we all have to wait to find out more! (There is a previous biopsy, but I'm not telling...heehee)

Until next time, Angelica

A Great Start! - Week 1

Well, after a bit of a long flight through Dubai (a high-tech, luxurious city) and then a less long hop across Saudi Arabia, the Red Sea and several African countries, I finally landed in this wonderful country on Monday night.

Dr. Garcia and our friend/driver, Phillip, met me at the airport.  We arrived home after an hour drive through several mountain towns and the sweetest air, perfumed with flowers and tea fields. This is the obligatory photo of the view from the "Path house" - It's too stunning not to share.

Work started in earnest on Tuesday. Two pull-through colectomy cases, from older kids, who ate REAL food and had REAL poop. A bit different than what we have at home.

Before opening the bucket

Prep Work in the Squat Toilet

While we are on the subject, an important lesson:

Toilet Paper Plant
( fuzzy stem)

Stinging Nettle
(thorny stem)

DO NOT CONFUSE THESE PLANTS!



The remainder of the hike was wonderful, with weather familiar to us in the Pacific Northwest, drizzly "Seattle Sunshine" (TM - The Chandler Family).

Trumpet Plant

The weather and the hike left us craving for the lovely tea that is found at a little shop in Magina, the village on top of the hill (elevation 2388m).

               


And I should also wish Dr. Garcia a Happy Birthday, even though I arrived the day after.  She did however spend it in good company:

And now, for those of you still reading... a bit of gross pathology from Kijabe. This case is a 26 year old woman with a 20 cm mass in the left ovary. (2 pics - answer next post)

Until next time...Angelica