The patient went on to have a laparotomy and resection of both an andrenal gland and a segment of small bowel.
Histology
MACROSCOPIC DESCRIPTION:
1. "Right adrenal gland": A disrupted lobulated irregularly shaped piece of tissue weighing 68g and measuring 120x40x30mm. The lesion appears to contain fat and areas of haemorrhage. The lesion has not been inked. Slicing reveals a pale rubbery focally haemorrhagic, focally viscous cut surface with central cystic degeneration. Normal residual adrenal parenchyma is not seen.
2. "Small bowel": A segment of small bowel measuring 100x40mm. The attached mesentery measures 15mm wide. Located 20mm from the nearest resection margin is a polypoid tumour with surface ulceration measuring 40mm in maximum dimension. The surrounding serosa is rugged and has been inked blue. The tumour has a firm cream cut surface and is focally haemorrhagic. It invades through muscularis propria and to the serosa.
MICROSCOPIC DESCRIPTION:
1. Sections show adrenal gland which has been replaced by tumour. The tumour consists of sheets of tumour cells which have large cells. The cells in areas have large irregular folded nuclei and in some areas show prominent nuclear grooves and small nucleoli. There is a moderate amount of eosinophilic cytoplasm seen. In some areas the cells have a slightly epithelioid nature in the cytoplasm but in other areas are spindled.
2. Sections show small bowel which has a tumour located within the bowel wall which ulcerates through the mucosa. The tumour consists of sheets of tumour cells which have a similar morphology to the adrenal mass. Tumour invades through the full thickness of the bowel wall. No angiolymphatic involvement is seen. Up to 13 mitosis per 10 hpf are present. No necrosis is seen. Tumour extends into the muscularis propria but does not appear to penetrate through the serosa.
Immunohistochemistry shows tumour cells are positive with S-100, mlan-A and HMB-45. Focal positive with CD117. Negative in Cam5.2, CD20, CD45, Desmin, AE1/AE3, CD34, calretinin, CD3, CD30 and DOG-1.
FINAL DIAGNOSIS:
- Right adrenal gland: Malignant Melanoma
- Small bowel: Malignant melanoma