—  SPECIALTY CONFERENCE HANDOUT  — Gastrointestinal Pathology Sunday, February 27, 2011, 7:30 PM CC BRA Clinical histories are printed below. Click on the case numbers for text and references of each case. Click on each slide thumbnail image for an enlarged view Moderator: GREGORY Y. LAUWERS Massachusetts General Hospital Boston, MA Disclosure: In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose. Panelists: Amitabh Srivastava, Dartmouth Hitchcock Medical Center, Lebanon, NH David Driman, London Health Sciences Centre, London, Ontario, Canada Priyanthi Kumarasinghe, PathWest, Queen Elizabeth II Medical Centre, Perth, Australia Noam Harpaz, The Mount Sinai Medical Center, New York, NY Robert D. Odze, Brigham and Women Hospital, Boston, MA Clinical Histories and Still Images are displayed below. Click on slide thumbnail images for an enlarged view. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 - Click here for Text and References Submitted by: Amitabh Srivastava - Clinical Summary: A 65 year old man presented with abdominal pain, anemia and an unintentional 15 lb weight loss over the past six months. Colonoscopy revealed two small polyps but no evidence of malignancy. Upper GI endoscopy showed an ulcer with heaped up margins in the distal stomach. Biopsies from the lesion showed high-grade dysplasia and intramucosal adenocarcinoma. However, endoscopic ultrasound examination was consistent with a T2 lesion and a distal gastrectomy was performed. Case 1 - Figure 1 Case 1 - Figure 2 Case 1 - Figure 3 Case 1 - Figure 4 Case 1 - Figure 5 Case 1 - Figure 6 Case 1 - Figure 7 Case 1 - Figure 8 Case 1 - Figure 9 Case 1 - Figure 10 D2-40 immunostain Case 2 - Click here for Text and References Submitted by: David Kevin Driman - Clinical Summary: This 31 year old male presented with a one month history of profuse watery diarrhea and vomiting. He had had a heart transplant 2 years previously for familial dilated cardiomyopathy. Routine blood work was normal and his stools contained no ova or parasites. He was taking the following medication: tacrolimus, mycophenolate mofetil, aspirin, lansoprazole, atorvastatin and buproprion. Colonoscopy showed patchy erythema but there were no ulcers or other striking abnormalities. Several biopsies were taken. Case 2 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 2 - Figure 1 Patchy crypt architectural distortion, variable inflammation and scattered dilated crypts Case 2 - Figure 2 Dilated crypts containing neutrophils and cell debris; some crypts lined by hypereosinophilic epithelium with a regenerative apparance Case 2 - Figure 3 Increased lamina propria eosinophils, damaged crypt filled with neutrophils; other crypts showing reactive changes with hypermucinous epithelium Case 2 - Figure 4 Crypt epithelial apoptosis Case 2 - Figure 5 IBD type appearance with lamina propria edema and crypt architectural abnormalities Case 2 - Figure 6 Crypt distortion and branching Case 2 - Figure 7 Crypt distortion and loss in association with small dilated damaged crypts Case 2 - Figure 8 Small damaged crypts; one lined by hypereosinophilic regenerative type epithelium, the other dilated and lined by atrophic thinned epithelium Case 3 - Click here for Text and References Submitted by: Priyanthi Kumarasinghe - Clinical History: A 65 year old male underwent a total gastrectomy. A previous endoscopic biopsy showed a poorly differentiated adenocarcinoma. Her-2 status was assessed. Case 3 - Figure 1 Scanning magnification of the carcinoma Case 3 - Figure 2 Invasive adenocarcinoma with overlying high grade dysplasia Case 3 - Figure 3 Low power picture of the poorly differentiated areas of the tumour Case 3 - Figure 4 Poorly differentiated solid growth pattern Case 3 - Figure 5 HER-2 protein expression of the area shown in figure 3 demonstrating marked heterogeneity Case 3 - Figure 6 HER2 immunohistochemical expression of the dysplastic epithelium and invasive carcinoma in contrast to the negative non-neoplastic tissue Case 3 - Figure 7 HER-2 protein expression in the area shown in figure 2 that includes dysplastic and invasive areas Case 3 - Figure 8 HER-2 protein expression, scored as 3+ according to Hoffman et al Case 3 - Figure 9 HER-2 protein expression in vascular emboli Case 3 - Figure 10 HER-2 gene amplification with Silver In- Situ Hybridisation (SISH); tumour cells show high amplification Case 4 - Click here for Text and References Submitted by: Noam Harpaz - Clinical Summary: The patient was a 50-year-old male who presented with pain of the left upper extremity. He had been diagnosed with a rectal tumor 5 years earlier at another facility and treated with chemotherapy and local radiation. Radiological examination now revealed a large lytic tumor in the left humerus and further work-up revaled hepatic, pulmonary and intracranial lesions. A biopsy of the humeral tumor was performed and a slide of the original rectal biopsy was retrieved for comparison. Case 4 - Figure 1 Dyscohesive tumors cells with peripherally displaced nuclei. Inset: Biopsy tissue from lytic tumor of humerus Case 4 - Figure 2 Signet ring features, nuclear atypia and paranuclear zone at higher magnification Case 4 - Figure 3 Negative stains for DPAS, HMB45, CD45 and lambda light chain Case 4 - Figure 4 Cytoplasmic staining for AE1/AE3. The cytoplasmic staining is heterogeneous and occasionally globular Case 4 - Figure 5 Positive staining for synaptophysin Case 4 - Figure 6 Positive membranous staining for CD56 Case 4 - Figure 7 Ki-67 proliferation index = 10% Case 4 - Figure 8 Electron microscopy reveals small neuroendocrine granules and paranuclear aggregates of 10nm filaments Case 4 - Figure 9 Case 4 - Figure 10 Earlier rectal biopsy demonstrates invasive tumor arranged in irregular cords and single cells. Case 4 - Figure 11 Despite some crush artifact, similarity of the rectal tumor cells to those of the bone tumor is evident at high magnification. Case 4 - Figure 12 Second case of rectal signet ring neuroendocrine carcinoma. The tumor presented endoscopically as a 7cm rectal mass. Case 4 - Figure 13 Rectal biopsy shows the mucosa infiltrated by dyscohesive signet ring cells Case 4 - Figure 14 Negative stains for mucicarmine and BRST2 and positive stains for CAM5.2 and synaptophysin. Case 5 - Click here for Text and References Submitted by: Robert D. Odze - Clinical Summary: The case represents a 56 year old male with an 8 year history of Barrett's esophagus (BE). At initial diagnosis, the patient had long segment BE extending to 5 cm above the gastroesophageal junction (GEJ). At the time of the patient's most recent endoscopic surveillance, the length of esophageal columnar mucosa was 3.5 cm, and there were multiple foci of squamous islands. Four quadrant biopsies were obtained from every 2 cm of columnar-lined esophagus. No other endoscopic abnormalities were detected. The biopsy of interest represents mucosa obtained from 2 cm proximal to the GEJ. The patient has no family history of esophageal or colon cancer, and other biopsies from the upper GI tract (stomach and duodenum) were within normal limits. Case 5 - Figure 1 Case 5 - Figure 2 Handouts for all Specialty Conferences will be accessible via the "Educational Materials" section on the homepage the morning after each respective conference. Printed copies of the handout will not be available at the meeting.