—  SPECIALTY CONFERENCE HANDOUT  — Pulmonary Pathology Sunday, March 18, 2012, 7:30 PM Convention Centre 211-214 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 Neoplasms Presenting as Diffuse Lung Disease Moderator: THOMAS V. COLBY Mayo Clinic Arizona Scottsdale, AZ 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: Lindsay A. Schmidt , University of Michigan, Ann Arbor, MI Joanne Lynne Wright, University of British Columbia, Vancouver, BC, Canada Kirk D. Jones, UCSF, San Francisco, CA Anja C. Roden, Mayo Clinic, Rochester, MN William D. Travis, Memorial Sloan Kettering Cancer Ctr, New York, NY 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: Lindsay A. Schmidt - University of Michigan, Ann Arbor, MI Clinical Summary: The patient is a 12-year-old female who presents to her primary care physician with complaints of a 25 pound weight loss over 6 months, decreased appetite, a cough productive of brown sputum over the past two months, and occasional emesis. A plain chest x-ray was performed, showing diffuse interstitial opacities that are nodular in appearance and involve all lobes of both lungs. These changes are somewhat more pronounced in the lower lobes. By history, she lives in a rural setting and has exposure to both a barn and handles hay on a regular basis. She has no significant travel history or tuberculosis exposure. She was treated for pneumonia at the age of 4 but otherwise has no significant past medical history. One parent smokes in the home. Her physical exam is normal except for faint bibasilar crackles and digital clubbing. She is referred to a pediatric pulmonologist, who sends her for an open lung biopsy. Pertinent Laboratory Data: The patient has had a normal sweat chloride test. A sputum culture sent for acid fast bacilli was negative. Pulmonar function testing reveals moderate to severe restrictive disease with some air trapping and a low DLCO. Case 1 - Figure 1 H&E 20x Case 1 - Figure 2 H&E 40x Case 1 - Figure 3 H&E 40x Case 1 - Figure 4 H&E 100x Case 1 - Figure 5 H&E 100x Case 1 - Figure 6 H&E 200x Case 1 - Figure 7 H&E 200x Case 1 - Figure 8 H&E 400x Case 1 - Figure 9 H&E 400x Case 1 - Figure 10 H&E 400x Case 2 - Click here for Text and References Submitted by: Joanne Lynne Wright - University of British Columbia, Vancouver, BC, Canada Clinical Summary: Case History: 59 year old male HIV positive for 8 years: HAART therapy Rectal B cell lymphoma previous year treated conservatively Cutaneous Kaposi’s with eye involvement Previous admission 20 days prior to death for management Presents 5 days prior to death with: productive cough shortness of breath fatigue Physical Exam Multiple cutaneous Kaposi’s sarcoma lesions Bulky lymph nodes in bilateral inguinal and left posterior cervical areas Inspiratory crepitations in left mid lung and right lung base Radiology Admission Chest X-Ray: Infiltrates in both lower lobes and right middle lobe with subsegmental atelectasis and right basilar pleural effusion Marked septal thickening. CT: One week prior to admission: Peribronchial soft tissue infiltration with bronchial narrowing. Focal nodular infiltrates. Bilateral small pleural effusion. Three days after admission: Marked progression of disease with accentuation of lymphatics, increased nodularity, consolidation, and increase in size of pleural effusions. Case 2 - Figure 1 Gross specimen of lung Case 2 - Figure 2 Whole mount of selected slide Case 2 - Figure 3 High power magnification Case 3 - Click here for Text and References Submitted by: Kirk D. Jones - UCSF, San Francisco, CA Clinical Summary: 82-year-old woman with abnormal chest x-ray. A CT scan shows two adjacent right upper lobe nodules, both approximately 8 mm in diameter. A right upper lobe wedge resection was performed (9 x 3.5 x 2.8 cm) that showed a 1 cm diameter nodule. Case 3 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Figure 1 Low power view of pulmonary nodule shows necrotic center with peripheral small satellite nodules (H&E, 20x). Case 3 - Figure 2 Central portion of nodule shows typical coagulative necrosis with ghost-like pulmonary parenchymal structure still visible (H&E, 100x). Case 3 - Figure 3 The periphery of the nodule shows a granulation-tissue like fibrosis, while the smaller nodules have a rounded structure and are reminiscent of thrombosed vessels (H&E, 100x). Case 3 - Figure 4 Higher power view of the peripheral nodules shows atypical cells within the central portion (H&E, 200x). Case 3 - Figure 5 These atypical cells are characterized by enlarged, hyperchromatic, irregular nuclei with prominent nucleoli and scant to moderate amounts of cytoplasm (H&E, 400x). Case 3 - Figure 6 These atypical cells were almost nonexistent on the original H&E slides, but showed up in full force on the recut made for this conference (H&E, 400x). Case 3 - Figure 7 An EVG stain reveals the peripheral nodule to show a single elastic layer, indicative of an obliterated pulmonary vein (Elastic van Gieson, 200x). Case 3 - Figure 8 A p63 stain highlights the nuclei of the atypical cells (p63, 400x). Case 3 - Figure 9 A cytokeratin 5/6 stain shows cytoplasmic staining of the atypical cells (CK5/6, 400x). Case 4 - Click here for Text and References Submitted by: Anja C. Roden - Mayo Clinic, Rochester, MN Clinical Summary: This 42 year old man presented to the Emergency Department with sudden onset of sharp, non-exertional anterior chest pain. He denied any fever. The patient had a 25-pack year smoking history and also smoked marijuana for 20 years. Otherwise, his past medical history and family history were unremarkable. Physical examination revealed diminished bilateral breath sounds, bilateral coarse crackles, and markedly hyperinflated chest. He was treated with antibiotics for one week without clinical improvement. A chest X-ray was performed followed by a CT scan. Subsequently, the patient underwent wedge biopsy of the right middle and lower lung lobes. Case 4 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 4 - Figure 1 CT shows multiple bilateral cysts in the lower lung lobes in addition to nodular infiltrates in the left lung base. Case 4 - Figure 2 Low power view showing a nodular cellular infiltrate in a background of fibrosis and cysts (x 20). Case 4 - Figure 3 Higher power view showing lymphocytic infiltrate of cyst walls (x 40). Case 4 - Figure 4 The cellular infiltrate is comprised of monotonous appearing lymphocytes with focal clear cytoplasm involving a cyst wall lined by cuboidal epithelium (x 200). Case 4 - Figure 5 High power view showing an infiltrate that is composed of small lymphocytes and plasma cells (x 400). Case 4 - Figure 6 The cellular nodules are predominantly comprised of CD138 positive plasma cells (x 200). Case 4 - Figure 7 CD20 positive B cells form clusters (x 200). Case 4 - Figure 8 Immunostain for immunoglobulin kappa light chain highlights monotypic plasma cells (x 200). Case 4 - Figure 9 Amorphous material is present surrounded by chronic inflammation and organization (x 40). Case 4 - Figure 10 The amorphous material is focally bordered by multinucleated giant cells (x 400). Case 4 - Figure 11 Well-formed non-necrotizing granuloma with a small chronic inflammatory cuff are distributed in a lymphangitic pattern (x 40). Case 4 - Figure 12 High power view of non-necrotizing granuloma. Case 5 - Click here for Text and References Submitted by: William D. Travis - Memorial Sloan Kettering Cancer Ctr, New York, NY Clinical Summary: 77M with nodular bilateral lung infiltrates. 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 Case 5 - Figure 8 Case 5 - Figure 9 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.