—  SPECIALTY CONFERENCE HANDOUT  — Genitourinary Pathology Tuesday, March 20, 2012, 7:30 PM Convention Centre Ballroom A/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 A Potpourri of Interesting Urological Pathology Moderator: JOHN SRIGLEY The Credit Valley Hosp Mississauga, ON, Canada 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: Jesse K. McKenney, Stanford University, Stanford, CA Andrew J. Evans, Toronto General Hospital, Toronto, ON, Canada James Kench, Royal Prince Alfred Hospital, Sydney, Australia Esther Oliva, Mass General Hospital, Boston, MA 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: Jesse K. McKenney - Stanford University, Stanford, CA Clinical Summary: The patient is a 41 year old dialysis dependent man who was found to have a renal mass at routine imaging surveillance. Case 1 - Figure 1 Gross kidney showing a renal mass with extensive cystic change in the background kidney. Case 1 - Figure 2 Papillary growth of eosinophilic neoplastic cells. The neoplastic cells bridge between adjacent papillae to form cribriform or sieve-like structures. Case 1 - Figure 3 Neoplastic cells form a cribriform/sieve- like architectural pattern. Case 1 - Figure 4 High power magnification of intratumoral oxalate crystal. Case 1 - Figure 5 Background kidney shows numerous cysts lined by similar appearing eosinophilic cells. Case 2 - Click here for Text and References Submitted by: Andrew J. Evans - Toronto General Hospital, Toronto, ON, Canada Clinical Summary: A 47 year-old man presented with sudden onset painless, gross hematuria. He had no other urinary symptoms. He was a former cigarette smoker (1 pack per day for 25 years) having quit 10 years before presentation. His medical history was remarkable only for mild essential hypertension of 2 years duration. He works as an engineer in the airline industry and has no history of occupational exposure to known carcinogens. At cytoscopy, he was found to have a smooth dome-shaped mass on the right lateral wall of the bladder. Urine cytology was negative for malignant cells. The attached H&E slide is from the transurethral resection of the bladder mass. Case 2 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 2 - Figure 1 High magnification (400x) H&E features – polygonal cells with abundant basophilic granular cytoplasm and uniform nuclei with even, finely granular chromatin and inconspicuous nucleoli. Case 2 - Figure 2 Medium magnification (100x) H&E features – diffuse growth pattern (no nesting or zellballen) with prominent microvasculature. Case 2 - Figure 3 Low magnification (50x) H&E features – sub- mucosal location with a relatively well-defined border with the adjacent bladder stroma. Case 2 - Figure 4 Presence of tumor within muscularis propria Case 2 - Figure 5 Surface urothelium showing no dysplasia or carcinoma in situ. Case 2 - Figure 6 Negative staining of the tumor cells for pancytokeratin AE1/AE3 (right) in contrast to the expected positive staining of the surface urothelium (left). Case 2 - Figure 7 Immunhistochemical staining of the tumor for neuroendocrine markers. Case 2 - Figure 8 Negative immunohistochemical staining of the tumor cells for S100. Note that no sustentacular cells were identified. Case 2 - Figure 9 Immunohistochemical staining with SDHB – speckled, granular cytoplasmic staining in liver (positive control); negative staining of tumor cells in a pheochromocytoma from a patient with a known SDHB mutation; positive staining of the bladder pararganglioma in the present case. Case 3 - Click here for Text and References Submitted by: James Kench - Royal Prince Alfred Hospital, Sydney, Australia Clinical Summary: A 65 year old man presented to his urologist with urgency, poor stream and hematuria. Cystourethroscopy showed essentially normal bladder and urethra. A TURP was performed followed by a radical prostatectomy 1 month later. Pertinent Laboratory Data: His serum PSA was 1.8ng/mL. Case 3 - Figure 1 The TURP section shows invasive adenocarcinoma beneath intact urothelium. Case 3 - Figure 2 Low power view of the radical prostatectomy specimen shows adenocarcinoma involving the periurethral region and transition zone with focal extension into the peripheral zone. Urethra is seen at top right. Case 3 - Figure 3 PASd staining demonstrates abundant mucin in the neoplastic glands. A hyperplastic nodule is present at bottom right. Case 3 - Figure 4 In some areas the tumor consists of glands of varying size infiltrating the prostatic stroma. The tumor has an appearance reminiscent of colorectal carcinoma with necrotic debris and mucin present in the glandular lumens. Case 3 - Figure 5 The neoplastic glands are lined by columnar epithelium with palisaded nuclei and scattered mitotic figures. Case 3 - Figure 6 Small foci of tumor, each <2 mm diameter and centered on involved ducts, are present separated by non-neoplastic peripheral zone tissue. Case 3 - Figure 7 Prominent intraductal spread is present with an abrupt transition between neoplastic epithelium and benign prostatic epithelium. Case 3 - Figure 8 Immunostaining for high molecular weight cytokeratin 34βE12 highlights residual basal cells surrounding cribriform carcinoma within the ducts. Case 3 - Figure 9 Tumor is focally positive for HMW cytokeratin 34βE12. Case 3 - Figure 10 PSA is negative in the neoplastic epithelium and strongly positive in the surrounding prostatic acini and ducts. Case 3 - Figure 11 Diffuse positive staining for CEA. Case 3 - Figure 12 CDX2 is negative in most of the tumor. Case 3 - Figure 13 However, focally there is strong staining for CDX2, including some of the intraductal component. Case 4 - Click here for Text and References Submitted by: Esther Oliva - Mass General Hospital, Boston, MA Clinical Summary: A 76-year-old male was incidentally found to have a firm left testicular/scrotal mass of approximately 2 cm on physical exam. The patient had no known significant past clinical history. He underwent resection of the mass. On gross examination, the tumor measured 1.7 x 1.6 x 1.5 cm and was relatively well circumscribed with a white to tan, rubbery and homogeneous cut surface. Case 4 - Figure 1 individual and interanastomosing tubules are present in a collagenous background. Case 4 - Figure 2 interanastomosing cords and trabeculae are part of the tumor. Case 4 - Figure 3 small tubules show prominent vacuoles within the tumor cells. Case 4 - Figure 4 some tubules are lined by flattened cells and others are reminiscent of vascular spaces. Case 4 - Figure 5 some tubules are reminiscent of true glands. Case 4 - Figure 6 many cells have a signet-ring cell-like morphology. Case 4 - Figure 7 close up shows round to oval nuclei with homogeneous chromatin and small nucleoli. Case 4 - Figure 8 the tumor is associated at the periphery with a prominent lymphoid infiltrate forming lymphoid aggregates. 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.