—  SPECIALTY CONFERENCE  — Neuropathology Wednesday, March 21, 2012, 7:30 PM Convention Centre 220-222 Click the button above to add this event to your Itinerary Planner... Surgical Neuropathology: Lessons Learned from Dr. Bernd Scheithauer Moderator: Daniel Brat Emory Univ Hosp Atlanta, GA 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: Arie Perry, University of California, San Francisco, San Francisco, CA Rebecca D. Folkerth, Brigham & Women’s Hosp, Boston, MA Gregory N. Fuller, MD Anderson Cancer Center, Houston, TX Eyas M. Hattab, Indiana University, Indianapolis, IN Caterina Giannini, Mayo Clinic, Rochester, MN 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: Arie Perry - University of California, San Francisco, San Francisco, CA Clinical Summary: This 51-yo woman presented with new onset of headaches and left hemiparesis. MRI studies revealed a 5 x 3 x 3.5 cm. partially cystic, partially solid contrast enhancing right temporo-parietal mass with surrounding edema and a roughly 1 cm midline shift to the left. The lesion was in close proximity to the lateral ventricle and the radiologist favored a high-grade ependymoma or astrocytoma. A craniotomy and open biopsy was 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 2 Submitted by: Rebecca D. Folkerth - Brigham & Women’s Hosp, Boston, MA Clinical Summary: 55yo M with hypertrophic cardiomyopathy, status post orthotopic heart transplant 6 weeks prior - On mycophenylate mofetil, prednisone, and cyclosporine - At routine post-op visit, complained of 2 days of frontal headache and lethargy - Headache constant, 8/10, bifrontal, and unaffected by position; alleviated slightly by acetaminophen - No fever, neck stiffness, or vomiting - Wife reported he was less “like himself”, with paucity and slowing of speech, and emotional blunting - No recent travel or sick contacts; cats at home - Employed as a high school woodshop teacher, on leave for several weeks surrounding his heart transplant On examination - T 96.7F - BP 160/70 mmHg - Alert, oriented, and appropriately interactive, though with a reduced range of affect - Occasional paraphasic errors, and difficulty relaying complex portions of his history - Mild flattening of right nasolabial fold - Strength decreased in right triceps (4+/5) and bilateral ankle dorsiflexion (4/5) - Slight right pronator drift and decreased rapid finger- tapping with the right hand Labs: - WBC count 7.36; cyclosporine trough level was 243 ng/mL (therapeutic range: 100-400 ng/mL). Imaging (see Fig 2_a): - Axial T1 with gadolinium showed 3cm lesion with nodular signal heterogeneity - Axial FLAIR showed increased relative cerebral blood volume, moderate vasogenic edema, and 7mm midline shift Case 2 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 2 - Figure 1 Neuroimaging Case 2 - Figure 2 H&E 400x Case 2 - Figure 3 H&E 400x Case 2 - Figure 4 H&E 400x Case 2 - Figure 5 H&E 400x Case 3 Submitted by: Gregory N. Fuller - MD Anderson Cancer Center, Houston, TX Clinical History: A 20-year-old man presented with a two-day history of intermittently slurred speech. There was no history of other signs or symptoms, including no history of headache, nausea, vomiting, motor or sensory deficits, visual disturbance, seizures or altered level of consciousness. A non-contrast CT scan performed in the Emergency Department revealed a 4-cm-diameter heterogeneous mass in the region of the left basal ganglia (putamen and globus pallidus). Subsequent MR imaging demonstrated that the basal ganglia mass displayed heterogeneous contrast enhancement, central hypointense areas of apparent necrosis, and surrounding vasogenic edema. Stereotactic biopsy was performed. Case 3 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Figure 1 Axial T1W MRI with contrast Case 3 - Figure 2 Coronal T1W MRI with contrast Case 3 - Figure 3 Sagittal T1W MRI with contrast Case 3 - Figure 4 Axial T2W MRI Case 3 - Figure 5 Cytologic smear preparation - HE Case 3 - Figure 6 Frozen section - HE Case 3 - Figure 7 Permanent FFPE section - HE Case 4 Submitted by: Eyas M. Hattab - Indiana University, Indianapolis, IN Clinical Summary: The patient is a 75-year-old Caucasian man with past medical history significant for right shoulder “high grade pleomorphic sarcoma,” including right lower lobe metastasis. He presented to the emergency room with right- sided weakness but refused admission at that time. He had a similar episode approximately 48 hours later, prompting a return to the emergency room and admission. The patient's wife has also noted some word-finding difficulty for approximately a week accompanied by some decrease in appetite and weight loss. An MRI of the brain revealed a 6.4 x 2.5 x 4.5 cm extra-axial, vividly enhancing lesion centered at the high left frontoparietal region, which crossed the midline posteriorly. There were both prominent extradural and subdural components with erosion of the calvarium and elevation of the scalp, as well as an 8mm thick periosteal fluid collection. Susceptibility weighted imaging demonstrated signal changes within the mass consistent with hemorrhage. The patient underwent left parietal craniotomy for tumor resection. Case 4 - Figure 1 MRIs Case 4 - Figure 2 H&E Case 4 - Figure 3 H&E Case 4 - Figure 4 H&E Case 4 - Figure 5 H&E Case 4 - Figure 6 H&E Case 4 - Figure 7 H&E Case 4 - Figure 8 H&E Case 4 - Figure 9 H&E Case 5 Submitted by: Caterina Giannini - Mayo Clinic, Rochester, MN Clinical Summary: The patient is a 74-year-old man, who began noting intermittent difficulty with expressive language. He had problems coming up with the name of a familiar neighbor as well as remembering the name of an ingredient for stew. There was no associated weakness, alteration in awareness, vision, or sensation. A brain CT and subsequently an MRI were obtained. The CT showed an area of low attenuation in the left temporal lobe with tiny associated area of hyperattenuation. A subsequent MRI showed a left temporal large mildly enhancing lesion with mass effect as well as several other areas of abnormal T2 signal in both hemispheres. He underwent a stereotactic biopsy of the left temporal lobe lesion with the clinical suspicion of low- to intermediate-grade glioma, likely multifocal. Case 5 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 5 - Slide 2 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 Preoperative-CT Case 5 - Figure 6 Preoperative-MRI 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.