—  SPECIALTY CONFERENCE HANDOUT  — Bone & Soft Tissue Pathology Tuesday, March 20, 2012, 7:30 PM Convention Centre 301-305 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 Challenges in the Diagnosis of Bone and Soft Tissue Tumors Moderator: ANGELO DEI TOS General Hospital of Treviso Treviso, Italy 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: John R. Goldblum, Cleveland Clinic, Cleveland, OH Alexander Lazar, UT-MD Anderson Cancer Center, Houston, TX John S. J. Brooks, Pennyslvania Hospital, Philadelphia, PA Rita Kandel, Mount Sinai Hosp, Toronto, ON, Canada Andrew E. Horvai, Univ of California/SF, San Francisco, CA 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 - Click here for Text and References Submitted by: John R. Goldblum - Cleveland Clinic, Cleveland, OH Clinical Summary: 49-year-old female with a 7-cm posterior thigh mass Case 1 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 1 - Slide 2 Click to view with ImageScope Click to view with a Web-Based Viewer Case 2 - Click here for Text and References Submitted by: Alexander Lazar - UT-MD Anderson Cancer Center, Houston, TX Clinical Summary: Female age 53 with chronic renal failure. Case 2 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Click here for Text and References Submitted by: John S. J. Brooks - Pennyslvania Hospital, Philadelphia, PA Clinical Summary: An 88 year old male with end-stage renal disease, coronary artery disease, bladder cancer, diabetes and peptic ulcer disease, presented with nausea and vomiting and was found to have an intra-abdominal tumor. At exploratory laparotomy, the mass was attached to the stomach, transverse colon, and omentum. On sectioning, the mass was 18 x 10 x 10 cm., and was cystic, hemorrhagic, and necrotic; viable tumor was tan in color. A representative section is provided. Case 3 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Figure 1 Low power with tumor in wall of stomach. Case 3 - Figure 2 Hemorrhagic tumor with osteoclast giant cells (OGC). Case 3 - Figure 3 Atypical mitoses, OGCs, and pleomorphic tumor cells. Case 3 - Figure 4 High power with tumor cells along with OGCs. Case 3 - Figure 5 CD34 stain was negative. Case 3 - Figure 6 Focal SMA (smoothmuscle actin) present. Case 3 - Figure 7 Negative DOG1 stain (and CD117 - not shown). Case 3 - Figure 8 Focal typical spindle cell GIST Case 3 - Figure 9 Diffuse CD34 positivity (CD117 & DOG1 also positive) Case 4 - Click here for Text and References Submitted by: Rita Kandel - Mount Sinai Hosp, Toronto, ON, Canada Clinical Summary: A 22 year old female presented with a 6 month history of right shoulder pain. Radiological images showed a tumour predominately in soft tissue with involvement of the proximal humerus measuring overall 9 x 5.2cm. The lesion was biopsied and subsequently resected. Case 4 - Gross There is a large soft tissue tumour involving the proximal humerus. Case 4 - Figure 1 The tumour is composed of sheets of plump spindle cells with eosinophilic cytoplasm. Case 4 - Figure 2 At higher power cytological atypia is present. Mitotic activity is not prominent. Inflammatory cells can be seen percolating through the tumour. Case 4 - Figure 3 Some cells have vesicular nuclei. Some cells are epithelioid in appearance. No vascular differentiation is seen. Case 4 - Figure 4 The tumour cells are positive for keratin (AE1/AE3). Case 4 - Figure 5 Tumour cells are diffusely positive for Fli-1. Case 4 - Figure 6 INI-1 was retained. Case 4 - Figure 7 The tumour cells are positive for smooth muscle actin focally but negative for desmin, caldesmon and myf-4 as well as CD31. Case 5 - Click here for Text and References Submitted by: Andrew Horvai - Univ of California/SF, San Francisco, CA Clinical Summary: A 71 year old man, 60-pack year smoker, sought attention from his primary care physician for cough of several months duration and recent onset of left hip pain. Past medical history was notable for coronary artery disease. A chest X-ray revealed an ill-defined left sided mediastinal or hilar density. A lytic lesion was noted in the intertrochanteric portion of the left femur. He underwent fine needle aspiration biopsy of the left femur lesion. Case 5 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 5 - Figure 1 The plain AP radiograph of the chest demonstrates an ill-defined opacity in the left hilum or mediastinum. Case 5 - Figure 2 The plain AP radiograph of the left femur shows a destructive, lytic, lesion involving the intertrochanteric region. Cortical erosion is present. Case 5 - Figure 3 A coronal CT of the pelvis shows an ill-defined, lytic, permeative lesion of the femur without definite soft tissue extension. Case 5 - Figure 4 Papanicolau (d) stained smear and H&E stained cell block of fine needle aspiration material shows clusters of dyshesive, small ovoid to round cells with scant cytoplasm, granular chromatin and prominent nucleoli. Case 5 - Figure 5 Papanicolau (d) stained smear and H&E stained cell block of fine needle aspiration material shows clusters of dyshesive, small ovoid to round cells with scant cytoplasm, granular chromatin and prominent nucleoli. Case 5 - Figure 6 The tumor cells are weakly positive for CD99 in a membrane pattern. Case 5 - Figure 7 Weak, focal synaptophysin staining is also observed. Figure legends (post meeting material) Case 5 - Figure 8 Proximal femoral resection specimen. The patient sustained a pathologic fracture prior to surgery. Case 5 - Figure 9 Post-operative plain AP radiograph demonstrating left hip arthroplasty. Case 5 - Figure 10 CD99 immunopositivity in ES/PNET is typically diffuse in a membrane pattern. Case 5 - Figure 11 Five year survival of pediatric-type sarcomas in adults. Rhabdomyosarcoma (RMS) and EWS/PNET show distinctly worse prognosis in adults than children when controlled for stage but the same is not true for desmoplastic small round cell tumor (DSCRT). Case 5 - Figure 12 Gradualism in ES/PNET evolution. Although most adult malignancies require stepwise accumulation of mutations over decades, in many pediatric tumors such as ES/PNET, the initiating genetic change may represent a "shortcut." Additionally, the progenitor cell required for transformation is unique to the pediatric population. 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.