—  SPECIALTY CONFERENCE HANDOUT  — Gastrointestinal Pathology Thursday, March 22, 2012, 7:30 PM Convention Centre Ballroom B 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 Mass 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: Joel Greenson, Univ/Michigan Hospitals, Ann Arbor, MI Tomas Slavik, Ampath Pathology, Pretoria, South Africa Ian S. Brown, Envoi Pathology, Herston, Queensland, Australia Vikram Deshpande, Massachusetts General Hospital, Boston, MA Marco Novelli, University College London, London, United Kingdom 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: Joel Greenson - Univ/Michigan Hospitals, Ann Arbor, MI Clinical Summary: The patient is a 78 year-old man with a previous medical history of COPD, type 2 diabetes mellitus, pulmonary hypertension, degenerative joint disease, chronic kidney disease, gastroesophageal reflux, and chronic anemia with eosinophilia. His anemia was worked up in 2005 with a bone marrow that only showed eosinophilic hyperplasia. He was recently discharged from the hospital after developing pneumonia that was treated with antibiotics and steroids. He was readmitted for shortness of breath. Chest X-ray showed bilateral pulmonary infiltrates and blood cultures grew out vancomycin-resistent enterococcus. The patient began complaining of abdominal pain and constipation which led to a CT scan that showed a diffuse circumferential thickening of right colon that was interpreted as being “consistent with colitis”. Colonoscopy revealed erythema and decreased vascular pattern consistent with “mild non-specific colitis.” Random colon biopsies were taken. Pertinent Laboratory Data: WBC count 16.0 with 16.4% eosinophils. Absolute eosinophil count 2.62 (upper limit of normal 0.5) Case 1 - Figure 1 Low-power view of 4 mucosal biopsies showing architectural distortion and increased inflammation of the lamina propria. Case 1 - Figure 2 Two biopsies with increased chronic inflammation and crypt distortion resembling ulcerative colitis. Case 1 - Figure 3 Medium-power view highlighting lamina propria inflammation with basal plasma cells and clusters of eosinophils. Case 1 - Figure 4 Higher-power view of "eosinophilic microabscess" and basal plasma cells. Case 1 - Figure 5 High-power view showing Strongyloides organism on the lower right. Note the rows of nuclei that almost look like small yeast. Also note single multinucleated giant cell and eosinophils adjacent to the nematode. Case 1 - Figure 6 Similar view showing another organism with a rim of histiocytes and eosinophils around it. Case 2 - Click here for Text and References Submitted by: Tomas Slavik - Ampath Pathology, Pretoria, South Africa Clinical Summary: A 37 year old African woman presented with a 2 month history of crampy abdominal pain, and no other clinical or prior medical history of note. Upper and lower gastrointestinal endoscopy findings were within normal limits. At laparotomy for intestinal obstruction, a 28 cm segment of partly distended distal small bowel was resected. This revealed a 2.3 cm firm greyish-white mural tumor. Case 2 - Figure 1 Macro - Macroscopy of obstructing ileal tumor with mural kink Case 2 - Figure 2 HE x4 - Low power view of tumor extending into intact overlying mucosa Case 2 - Figure 3 HE x10 - Tumor showing insular/nested growth pattern Case 2 - Figure 4 HE x10 - Areas of acinar tumor growth Case 2 - Figure 5 HE x40 - Monomorphic tumor cells with round nuclei and inconspicuous nucleoli Case 2 - Figure 6 HE x4 - Extension of tumor into subserosal fat Case 2 - Figure 7 Ki-67 x10 - Ki67 immunoperoxidase stain showing low proliferative index (1%) Case 2 - Figure 8 HE x4 - Pronounced granulomatous inflammation directly adjacent to tumor Case 2 - Figure 9 HE x10 - Granulomas with central degenerated parasite ova Case 2 - Figure 10 HE x40 - Eosinophil-rich granuloma with central elongated parasite ovum Case 2 - Figure 11 HE x4 - Mesenteric lymph node with metastatic tumor Case 2 - Figure 12 ZN x40 - Acid-fast parasite ova and spine (Ziehl-Neelsen stain) Case 2 - Figure 13 HE x10 - Adult parasite worm in small subserosal vein Case 2 - Figure 14 HE x10 - Pair of parasite worms displaced into bowel lumen Case 3 - Click here for Text and References Submitted by: Ian S. Brown - Envoi Pathology, Herston, Queensland, Australia Clinical History: Male 60 years. Colonoscopy performed for investigation of a positive fecal occult blood test. Solitary 25 mm long filiform polyp removed from the sigmoid colon. No history of previous colorectal disease. Case 3 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Figure 1 Case 4 - Click here for Text and References Submitted by: Vikram Deshpande - Massachusetts General Hospital, Boston, MA Clinical Summary: 79 year old man with recent onset of diarrhea and weight loss and eventual jaundice. CT scan demonstrated a 3x4 cm mass in the head with multiple cysts within the mass measuring up to 0.9 cm. An EUS guided fine needle aspiration biopsy showed low grade mucinous epithelium and the cyst fluid CEA measured 685 IU/ml. A Whipple resection and cholecystectomy was performed. 10 years prior to to this episode of jaundice this patient presented with a lesion on the scalp. A biopsy was performed at an outside hospital and a diagnosis of 'pseudolymphoma' was made. Case 4 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 4 - Figure 1 Case 4 - Figure 2 Case 4 - Figure 3 Case 4 - Figure 4 Case 4 - Figure 5 Case 4 - Figure 6 Case 4 - Figure 7 Case 4 - Figure 8 Case 4 - Figure 9 Case 5 - Click here for Text and References Submitted by: Marco Novelli - University College London, London, United Kingdom Clinical Summary: A 12 year old boy of Arabic origin presented with a microcytic anaemia. Clinical examination revealed cutaneous stigmata of neurofibromatosis and neurological symptoms. CT scanning showed a brain tumour (subsequently found to be a glioblastoma multiforme on biopsy). Colonoscopy showed multiple colorectal tumours. Subtotal colectomy was performed. Case 5 - Figure 1 Case 5 - Figure 2 Case 5 - Figure 3 Case 5 - Figure 4 Case 5 - Figure 5 Case 5 - Figure 6 MLH1 Case 5 - Figure 7 PMS2 Case 5 - Figure 8 MSH2 Case 5 - Figure 9 MSH6 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.