SAN PEDRO COLLEGE Bachelor in Medical Laboratory Science INTERNSHIP PROGRAM MESENTERIC LYMPHANGIOMA A Case Analysis in HISTOPATHOLOGY Basio, Kim Well James F. Batara, Hanza M. Batchar, John Robert C. Battad, Leah Rose A. Bautista, Ashley Glen O. Bautista, Leo Gabriel V. Bauzon, Mariane Bea D. Becerra, Carla Jasmin A. Belarmino, Angelica E. Beray, Krystel Jean D. Bernaldez, Charles B. June 29, 2022 A Pediatric Case Report: A 3-year-old male child presented with pain in the abdomen on and off for 2 years with increased severity for 7 days. The pain was more during the night time and aggravated while feeding. It was associated with nonprojectile vomiting. There was also history of passage of hard stool once in 4-5 days, and for 2 days, the child had not passed urine. According to the father, the child had lost some weight. His past medical, surgical, and family history was unremarkable. On general examination, the child appeared malnourished and pale. On per abdominal examination, a mass of around was palpable just below the umbilical region. There was no abdominal distension. Bowel sounds were present. Other systemic examinations were normal. The laboratory investigations during the time of admission, viz., complete blood count, PT-INR, and serum electrolytes, were within normal limit. However, blood urea was 53.03 mmol/L (3.57-16.07 mmol/L), and serum creatinine was 176.84 μmol/L. His random blood sugar was 4.44 mmol/L (4.55-7.77 mmol/L). Gradually, after few days of admission, the renal function test returned to normal limit. All serological tests for human immunodeficiency virus, hepatitis B virus, and hepatitis C virus were negative. The total protein was within normal limit, i.e., 45 gm/L (63-82 gm/L). His routine urine examination showed 2-3 white blood cells per high power field. Ultrasonography (USG) of the abdomen showed an echogenic lesion measuring in the lower abdomen and pelvis with twisting of vessels and mesentery in the periumbilical region. It was reported as differential diagnosis of mesenteric mass and thickened mesentery. Computed tomography (CT) scan of the abdomen and pelvis revealed a large welldefined, lobulated homogenous no enhancing cystic mass lesion with thin walled internal septation in the peritoneal cavity measuring and was reported as mesenteric lymphangioma. There was also swirling appearance of the mesentery and superior mesenteric vein around the superior mesenteric artery in an anticlockwise direction representing midgut malrotation with mid-dilatation of bowel loops suggesting volvulus. Laparotomy was performed. During the operation, a huge mesenteric tumor mass measuring attached with the small intestine along with midgut malrotation was found. The tumor was excised completely with small bowel resection comprising of around 10 cm of distal jejunum and proximal ileum followed by anastomosis of proximal to distal segment. The operation procedure was uneventful with minimal blood loss (approximately 100 mL) and took only around 45 minutes to complete. The procedure was well tolerated by the patient without any clinically significant postoperative complications. 1 Picture 1 Picture 2 Picture 3 Picture 4 Picture 5 2 QUESTIONS: 1. Give the 6 components of gross description. a. Pt’s name/sex, specimen label, fresh/fixed - Name: N/A - Age: 3 years old - Sex: Male - Specimen label: 1076/20 - There is a huge mesenteric tumor mass and tumor was excised completely with small bowel resection comprising of around 10 cm of distal jejunum and proximal ileum. b. Main pathologic findings Type of lesion, size, shape, margins, etc. - The patient's abdominal and pelvic CT scan revealed a prominent, welldefined, lobulated, homogenous, non-enhancing cystic mass lesion within the walled internal septation of the peritoneal cavity. - Further examination also revealed that the mesentery appears to have thickened. Also, the mesentery and the superior mesenteric vein circle the superior mesenteric artery counterclockwise. - Lastly, a sizable mesenteric tumor mass was found that is consequently connected to the small intestine. The removed tumor mass is depicted in images 3-5 as having a lobulated semi-translucent, pale white, and spongy look. c. Any secondary findings - Some of the lumen appear to have eosinophilic secretions with few collections of lymphocytes and occasional red blood cells (RBCs). - Various calibered lymphatic channels lined by flattened endothelium are cystically dilated - Numerous focal nodular regions have a cut surface of the intestines containing a milky fluid. - The intervening fibrocollagenous stroma is edematous which has sparse lymphocytic infiltrate, and congested blood vessels. - The intestinal section showed lymphatic channels involving the muscularis propria, mucosa, and submucosa. d. Any normal structures - 10cm of distal jejunum and proximal ileum were removed during small bowel resection; remaining parts of the mucosa was unremarkable e. Any other special studies - Complete blood count, PT-INR, and serum electrolytes, were within normal limit - Blood urea nitrogen and serum creatinine are highly increased 3 - - - Serological test: HIV, Hepa B virus, and Hepa C virus were negative Random blood sugar is decreased Ultrasonography – A mesentery and echogenic lesion with twisted vessels may be seen in the periumbilical region of the lower abdomen and pelvis. Laparotomy - Both the midgut malrotation and a massive mesenteric tumor mass attached to the small intestine were detected. Through small bowel resection of the distal jejunum and the segment proximal to it, the tumor was completely removed. Compound tomography scan (CT-Scan) - A massive, well-defined, homogeneous, non-enhancing cystic mass lesion with thin-walled internal septation was found in the peritoneal cavity. Furthermore, the mesentery and superior mesenteric vein had a spiral appearance, the midgut had malrotation, and the bowel loops had mild dilation, all of which suggested volvulus. f. List of the cassettes and types of tissue sampled Tissue The sampled tissue is from the small intestine along with the midgut malrotation. Excisions include the huge mesentery with small bowel resection of around 10 cm of distal jejunum and proximal ileum. Thus, histological tissue was taken from the primary mass tumor and small intestine. Cassette Although there are no specifications in the case, the cassettes likely included are the Cassette A1-3: Tumor and Small Intestine (distal jejunum and proximal ileum) and Cassette A4: Tumor and Normal Small Intestine (distal jejunum and proximal ileum). 2. What fixative is recommended for the specimen? Why? a. The recommended fixative for the specimen is buffered formaldehyde. Formaldehyde fix tissues by forming linkages in the lysine residues found in proteins, which does not harm or alter protein structures significantly, thus the antigenicity of the proteins for immunohistochemical techniques are not lost. Maintaining the antigenicity allows the determination of markers in certain tumors. Also, the formaldehyde must be buffered to neutralize the acidity of the fixative which promotes autolysis of cells. 3. Probable Diagnosis - The patient most likely has a mesenteric lymphangioma (ML). A huge, lobulated, yellow to pink, cystic mass measuring 20 cm x 20 cm x10 cm that originates from the small bowel mesentery with small-bowel volvulus and dilatation is typical of ML intraoperative findings. Majority of these findings coincide with the ultrasonography and laparotomy results of the patient. 4 However, the most clinically significant of these are cystic masses and smallbowel volvulus, which most likely caused the patient's symptoms (pain in the abdomen, the passage of hard stool, etc.). Lastly, epidemiological studies have revealed that this type of tumor is relatively rare, with an incidence of 1: 250,000, and frequent in children, with 60% appearing at birth and 40% appearing by early childhood. This data also corresponds to the case because the patient is three years old. 5 References Abdulraheem, Sharie, Shalakhti, Alayoub, Domaidat, & El-Qawasmeh. (2021). Mesenteric cystic lymphangioma: A case report. International Journal of Surgery Case Reports, 80. doi:https://doi.org/10.1016/j.ijscr.2021.105659 Aprea, Guida, Canfora, Ferroneti, Giugliano, Cicirello, . . . Amato. (2016). Mesenteric cystic lymphangioma in adult: a case series and review of the literature. BMC Surg, 13(1). From https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3847351/ Blick, Grietta, Sprayberry, Bush-Vadala, Paulk, Boeckman, . . . Rech. (2019). Comparison of 2 fixatives in the porcine colon for in situ microbiota studies. J Anim Sci., 97(12), 4803–4809. Chen, Du, & Wang. (2018). Experience in the diagnosis and treatment of mesenteric lymphangioma in adults: A case report and review of literature. World J Gastrointest Oncol., 10(2), 522-527. Peixoto, Silva, Pereira, & Macedo. (2016). Biopsies in Gastrointestinal Endoscopy: When and How. GE Port J Gastroenterol., 23(1), 19-27. Suthiwartnarueput, Kiatipunsodsai, Kwankua, & Chaumrattanakul. (2012). Lymphangioma of the small bowel mesentery: A case report and review of the literature. World J Gastroenterol, 18(43), 6328-6332. 6 DOCUMENTATION 7
