—  SPECIALTY CONFERENCE  — Neuropathology Tuesday, March 1, 7:30 PM CC 006 C/D Neuropathology for the General Surgical Pathologist Moderator: DAVID N. LOUIS 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: Gregory Fuller, M.D. Anderson Cancer Center, Houston, TX M. Bea Lopes, University of Virginia Health Science Center, Charlottesville, VA Arie Perry, University of California, San Francisco Medical Center, San Francisco, CA Daniel Brat, Emory University Hospital, Atlanta, GA Christine Fuller, Medical College of Virginia, Richmond, VA Clinical histories are displayed below. For the fastest viewing of virtual slides, click: under each thumbnail image below. You must have Aperio ImageScope installed on your PC. If you do not already have Aperio ImageScope, Windows users with administrator privileges may download and install a free version in order to view USCAP Virtual Slides. Click the icon on the right to get your free copy:   Or, click on slide thumbnail images to view each slide in a Web-based slide viewer, which is somewhat slower. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 Submitted by: Gregory N. Fuller - Clinical Summary: A 35-year-old man presented with a 6-month history of recurrent coordination difficulties, most noticeable when engaged in racket sports. MR imaging revealed a lesion of the left frontal lobe with the imaging characteristics illustrated in the Figures. Imaging studies included MR Spectroscopy, with the results illustrated. Biopsy of the lesion was subsequently performed. Case 1 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer 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 Case 1 - Figure 11 Case 1 - Figure 12 Case 2 Submitted by: M. Beatriz Lopes - Clinical Summary: The patient is a 72-year-old gentleman with no previous history of neurologic disease who was referred to University of Virginia with history of subacute altered mental status and multiple brain lesions. The patient developed urinary incontinence three weeks prior presentation followed by episodes of confusion, ataxia, and slurred speech. CT and MRI of the brain at the outside hospital showed cerebral edema and about 7 enhancing lesions concerning from metastases versus infection. CT scans of the chest, abdomen, and pelvis were unremarkable. The patient was noted to have only an intention tremor at the outside hospital on neurological exam. The patient was placed on dexamethasone at the outside hospital and transferred to the University of Virginia. Of note, the patient had a PSA at an outside hospital about a year ago that was within normal limits, and also had a fecal occult blood was negative. The patient presented to University of Virginia with continued ataxia and confusion. He denied any fevers, chills, shortness of breath, neck pain, nausea, vomiting, or diarrhea. No weight loss. No night sweats. The patient complained of occasional paresthesias at his fingertips. On arrival, the patient's temperature was 36.2 degrees, blood pressure was 150/74, pulse was 62, respiratory rate 16, O2 saturation was 97% on room air. In general, the patient was in no apparent distress, alert and oriented to person and that he was in the hospital. However, he was not oriented to date or specific situation, also had occasional slurred speech. The patient's HEENT exam was unremarkable. Remaining physical exam was unremarkable. Neurologic exam showed the cranial nerves, II through XII are intact. Sensation was intact. He had 5/5 strength throughout. Cerebellar exam did show finger-to-nose dysmetria and slowing of alternating hand movements. He was unable to walk secondary to ataxia. He also had an intention tremor bilaterally. The patient underwent biopsy of one of the brain lesions on the same day as arrival. Case 2 - Figure 1 Case 2 - Figure 2 Case 2 - Figure 3 Case 2 - Figure 4 Case 2 - Figure 5 Case 2 - Figure 6 Case 2 - Figure 7 Case 2 - Figure 8 reticulin Case 2 - Figure 9 CD79a Case 2 - Figure 10 CD3 Case 2 - Figure 11 CD68 Case 3 Submitted by: Arie Perry - Clinical History: This 11-yo boy presented with a 1 week history of headaches, nausea/vomiting, and gait difficulties. Head CT revealed a paravermian left cerebellar mass with associated obstructive hydrocephalus. A subtotal resection was performed. Case 3 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Figure 1 Case 3 - Figure 2 Case 3 - Figure 3 Case 3 - Figure 4 Case 3 - Figure 5 Case 3 - Figure 6 Case 3 - Figure 7 Case 3 - Figure 8 Case 4 Submitted by: Daniel J. Brat Clinical Summary: This 10-month-old girl had a history of perinatal arrhythmia for which she recieved a cardiovascular work up and body CT at the age of 1 month. Body CT was negative at that time. She recently fell from the couch onto the floor and hit her head, resulting in a bruise, but without loss of consciousness. At the pediatric emergency department, aside from bruising on the scalp, the physical exam was normal. However, the head CT and subsequent MRI revealed a large, heterogenesously contrast-enhancing mass in the posterior fossa, centered in the cerebellum. One week later, she was taken to the operating room, where a near- total resection was achieved. Case 4 - Figure 1 MRI Case 4 - Figure 2 H&E Low Case 4 - Figure 3 H&E High Case 4 - Figure 4 H&E High Case 4 - Figure 5 H&E High Case 4 - Figure 6 H&E High Case 4 - Figure 7 Synapto Case 4 - Figure 8 Cytoker Case 4 - Figure 9 Actin Case 4 - Figure 10 INI1 Case 5 Submitted by: Christine E. Fuller - Clinical Summary: A 5 year-old girl presented with one month history of nausea, vomiting, "blurry vision", and morning headaches. Her physical exam was significant for upbeat nystagmus and left cranial nerve VI palsy. MRI revealed a large posterior fossa mass within the forth ventricle with heterogeneous signal characteristics and contrast enhancement, as well as hydrocephalus.(Image a) A gross total resection was achieved. Total spine MRI revealed no evidence of metastases, and lumbar puncture yielded negative cytology. A representative H&E image is provided (Image b). She received radiation therapy to the tumor bed. Multiple subsequent MRIs were negative; however she was lost to follow-up for nearly a year. Approximately 28 months post therapy she presented with 2 week history of intractable headache, nausea, and vomiting. MRI showed a large heterogeneously-enhancing mass within the frontal horn of the left lateral ventricle and post-operative changes only within the posterior fossa.(Image c) A left frontal craniotomy, ventriculostomy, and lumbar puncture were performed. Gross total excision was achieved, CSF cytology was negative, and MRI of the total spine was negative for metastases. She has received radiation therapy for this second lesion and shows no evidence of recurrence / progression to date. Pertinent Laboratory Data: Representative images of the left ventricular lesion are provided (images 4-7) as well as a virtual slide for your review. Case 5 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 5 - Figure 1 Case 5 - Figure 2 Case 5 - Figure 3 Case 5 - Figure 4 Case 5 - Figure 5 Case 5 - Figure 6 Case 5 - Figure 7 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.