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The patient is an 80 60 year old male who presented to the Emergency Department with a chief complaint remote history of right flank an abdominal melanoma that was excised with negative margins. The patient has been experiencing lower back painfor the past several months and has received epidural injections. He described the pain as As a 10/10 pain in his right flank. He denied any associated symptoms with this pain. He denied constipation, cough, shortness part of breath, fever, dysuriathe workup, hematuria, nausea, or diarrhea. He could not identify anything that made the pain worse or betterpatient had a CT which revealed retroperitoneal lymphadenopathy. He did take 5mg A CT guided fine needle aspiration and biopsy of acetaminophen-hydrocodone and did not have any relief. He had just taken his evening medications when the pain began, and he can not identify any activity that may have caused the paina paracaval lymph node was performed.

* Chronic obstructive pulmonary disease2003 Melanoma* Allergic rhinitisDiabetes

* 1993 Disk arthroplasty2013 Arthroscopic knee surgery* 2002 Coronary artery bypass with grafting2003 Excision of melanoma* 2009 arthroplasty* Cholecystectomy year unknown2002 Discectomy

Differential The differential diagnosis for flank pain includes: kidney stone, vertebral compression fracture,and infection. The suspicion for kidney stone was highest on the list. A urine cultureotherwise asymptomatic lymphadenopathy in this patient is melanoma, abdominal CTlymphoma, and POC urine were orderedor occult malignancy.

* PET CT scan revealed multiple lytic showed hypermetabolic activity with an SUV of 12.7. * CT of abdomen and sclerotic lesions within pelvis showed adenopathy adjacent to the thoracolumbar spine aorta and sacrum. These were thought inferior to be suspicious the vena cava at the level of metastatic disease. Wall thickening in the descending colon was seen and was thought to possibly represent a primary colon cancerright kidney. The prostate was enlargedlargest node measured 4 cm in greatest dimension.

CytologicallyYoursCoW20131202Cytology1.jpg|This is a 10x magnification the cytology specimen from the spinal massof paracaval lymph node. We see red blood cells and There is a cohesive group of polymorphic lymphoid population with scattered large atypical cells in this field. CytologicallyYoursCoW20131202Cytology2.jpg|This is a 20x magnification of the cytology specimen from the spinal massparacaval lymph node. We can see red blood cells in the There are small lymphocytes with background and a cohesive group of cells in this field. CytologicallyYoursCoW20131202Cytology3.jpg|This is a 60x magnification of the cytology specimen from the spinal masslymphoglandular bodies. We can see this group of cohesive cells have round nuclei, prominent nucleoli, Scattered eosinophils and ample cytoplasm.CytologicallyYoursCoW20131111Cytology4.jpg|This is a 60x magnification of the cytology specimen from the spinal mass. Again we have a cohesive group of large atypical cells that have ample cytoplasm, round nuclei, and some with prominent nucleoli.CytologicallyYoursCoW20131111Cytology5CytologicallyYoursCoW20131202Cytology3.jpg|This is a 60x magnification of the cytology of the specimen from the spinal mass. CytologicallyYoursCoW20131111Cytology6.jpg|This is a 40x magnification of single cells in cytology specimen from the spinal massparacaval lymph node. These single There are atypical binucleated cells are much larger than among the red blood large atypical cells, have ample cytoplasm, and are larger than the lymphocytes that are also present in the image. 

* <spoiler text="Benign or malignantWhat is your differential diagnosis?">These groups of cohesive cells are larger than the normal elements we would expect to find demonstrate malignant appearing cells in a touch prep from a spinal biopsybackground of an otherwise benign appearing lymphoid background. ThisThe atypical cells are scattered, along with large nucleoli and several binucleate forms. In addition, there seem to be an increased number of eosinophils in the patient's historybackground. The differential diagnosis includes Hodgkin lymphoma; however, should make you think that there is a malignant process involving the spinepossibility of the large atypical cells being melanoma cannot be ruled out. </spoiler>* <spoiler text="What ancillary tests would you call this on a Rapid Interpretationrecommend?">This is For this patient, we recommended that the radiologist perform a male patient with no previous history biopsy of malignancy. Our differential diagnosis can include many entities. However, these are cohesive cells the lesion so lymphoma should that it could be at sent for immunohistochemical workup. Since the bottom overall percentage of our list. We would need more information to classify these the atypical cellswere low, but we were worried that a diagnosis cell block would not contain enough of positive the malignant cells for additional stains. We also sent the lymph node for flow since a hematologic malignancy (was suspected; however, with no further specificity) can Hodgkin lymphoma, we don't expect any diagnostic findings from flow cytometry.</spoiler>* <spoiler text="What immunohistochemical stains would you do?">CD15, CD30, and PAX5 would stain tumor cells in Hodkin lymphoma. Mart1, HMB45, and S100 could be renderedused to rule out melanoma. Other additional stain in a lymphoma versus melanoma workup might include CD3, CD20, and keratin.</spoiler>

====Immunohistochemistry====<gallery heights="250px" widths="250px">CytologicallyYoursCoW20131111Biopsy7.jpg|PSA, 2x magnification. Note the predominance of brown staining in the middle.CytologicallyYoursCoW20131111Biopsy8.jpg|PSA, 60x magnification. The glands are highlighted in brown, and on the upper right the blood vessels are negative.</gallery> =====Resident Questions=====* <spoiler text="If you could only have one stain, what stain would it be?">This is a male patient with a new spinal mass. The spinal mass has glands made of cells with prominent nucleoli. In a case like this you should consider prostate as the source of the malignancy. A PSA stain would help highlight cells of prostatic origin.</spoiler><div class="usermessage mw-customtoggle-diagnosis" style="cursor:pointer">Click here to toggle the diagnosis and case discussion.</div>

* '''Positive for malignancy, the differential diagnosis includes melanoma and Hodgkin lymphoma'''. 

<gallery heights="250px" widths="250px">CytologicallyYoursCoW20131202Biopsy1.jpg|20x magnification of lymph node core biopsy.CytologicallyYoursCoW20131202Biopsy2.jpg|40x magnification of lymph node core biopsy. CytologicallyYoursCoW20131202Biopsy3.jpg|CD 15 with membranous staining.CytologicallyYoursCoW20131202Biopsy4.jpg|CD 30 with membranous staining.  </gallery> ===Biopsy Diagnosis===* '''Metastatic prostatic adenocarcinomaClassical Hodgkin lymphoma, favor mixed type'''.** CD15 Positive in tumor cells** CD30 Positive in tumor cells** PAX5 Weakly positive** CD20 Positive in background lymphocytes** CD3 Positive in background lymphocytes** S100 Negative** Mart1 Negative** HMB45 Negative ===Discussion===The features of Hodgkin lymphoma include atypical (Hodgkin cells) and Reed-Sternberg cells. The nucleus should be 3-4x the size of a small lymphocyte. In classic Hodgkin lymphoma, scattered eosinophils, plasma cells, histiocytes, and a predominately CD3+ lymphocyte population will be seen in the background. The immunophenotype of classic Hodgkin lymphoma shows CD15, CD30, MUM1, and weak PAX5 positivity. Histology is usually needed to subtype Hodgkin lymphoma.