—  SPECIALTY CONFERENCE HANDOUT  — Surgical Pathology Monday, March 19, 2012, 7:30 PM Convention Centre Ballroom A–D 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 The Best Damned Teaching Case You Have Ever Come Across in Your Specialty Moderator: HENRY APPELMAN Univ of Michigan Hosp Ann Arbor, MI 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: Laura C. Collins, Beth Israel Deaconess MC, Boston, MA Milton J. Finegold, Texas Children’s Hosp, Houston, TX Wendy L. Frankel, The Ohio State University, Columbus, OH Teri A. Longacre, Stanford University, Stanford, CA Scott Owens, University of Michigan, Ann Arbor, MI 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: Laura C. Collins - Beth Israel Deaconess MC, Boston, MA Clinical Summary: The patient is an 80 year old female with a past history of breast cancer. The specimen is a core needle biopsy, received with the radiologic differential diagnosis of recurrent tumor vs. fat necrosis. Case 1 - Figure 1 This low power image of the core biopsy shows sheets of hyperchromatic cells infiltrating through the collagenous stroma and fat. At this power the differential diagnosis includes carcinoma and perhaps even lymphoma. Case 1 - Figure 2 At intermediate power, highly malignant/undifferentiated tumor cells are appreciated. Case 1 - Figure 3 At highest power, the nuclei appear large and pleomorphic with prominent nucleoli. Mitoses and apoptotic debris are readily seen. An area of necrosis is present at the top of the field. Neither gland formation, nesting or a trabecular pattern is apparent. Case 2 - Click here for Text and References Submitted by: Milton J. Finegold - Texas Children’s Hosp, Houston, TX Clinical Summary: F.Q. – now 21 yo f 1998 Age 7 – abnormal LFT, high cholesterol 2001- cholecystectomy for stones 2003- ascites – KF rings; liver biopsy; chelation Rx (penicillamine, trientene) Pertinent Laboratory Data: 2005 – AST 85, ALT 80, AlkP 774, Bu 0.4, Bc 0; Pre-Alb 10.3; Serum bile acids x2 = 50; 149; A1AT M1,M3; lipids normal; AFP normal; normal Ceruloplasmin; low serum Cu; elevated 24 hr urine copper; Liver copper content 860 ug/gm; Mutation analysis negative for WD (Mayo) Case 2 - Figure 1 mallory body x500 Case 2 - Figure 2 x50 cirrhosis Case 2 - Figure 3 x100 micronodules Case 2 - Figure 4 x200 lymphocytes, piecemeal necrosis Case 2 - Figure 5 x400 copper Case 3 - Click here for Text and References Submitted by: Wendy L. Frankel - The Ohio State University, Columbus, OH Clinical Summary: 75 year old woman presented in May 2008 with painless, jaundice, pruritus, post-prandial epigastric pain and weight loss over the past month. CT scan showed a 4.9 cm mass in the head of the pancreas that did not extend into the adjacent vessels. She was thought to have a resectable pancreatic adenocarcinoma and was brought to the operating room for a Whipple procedure. After opening the abdomen, she was found to have a single, small subcapsular liver lesion. A frozen section was requested to determine whether the surgeons should proceed with the Whipple procedure or place a stent and abort the procedure. Case 3 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Figure 1 Scanning power view of the frozen section of the liver lesion. Case 3 - Figure 2 Medium power image of the previous showing a proliferation of cells arranged in nests and glands. Case 3 - Figure 3 High power image of the previous showing a proliferation of glands containing pigment (right upper) and nests/glands (center and left). Case 3 - Figure 4 High power image of the frozen section showing mild nuclear atypia without mitotic figures. Case 3 - Figure 5 High power image of the frozen section showing focal sheet/nests of cells with mild cytologic atypia without mitotic figures. Case 3 - Figure 6 Low power image of the permanent control of the frozen section of the liver. Case 3 - Figure 7 High power image of the previous showing a fairly regular proliferation of cells arranged in glands and nests. Case 3 - Figure 8 Cytokeratin AE1/3 immunostain showing weak staining in the tumor cells and strong staining in the proliferating bile ductules. Case 3 - Figure 9 Synaptophysin immunostain showing staining in the tumor cells but not bile ductules. Case 3 - Figure 10 The immunohistochemical stain for Ki67 showing a proliferative index of approximately 5 to 10%. Case 3 - Figure 11 Medium power image of the pancreas resection specimen showing a proliferation of fairly regular and round tumor cells with adjacent benign pancreatic acini (right). Case 3 - Figure 12 High power image of the previous showing a proliferation of fairly regular and round tumor cells arranged in nests and pseudoglands. Case 4 - Click here for Text and References Submitted by: Teri A. Longacre - Stanford University, Stanford, CA Clinical Summary: 54-year-old female with mucinous tumor involving the uterine corpus and cervix Case 4 - Figure 1 Mucinous proliferation in endometrium. Architecture is not overly complex, but shows villoglandular features. Case 4 - Figure 2 Mucinous proliferation in endometrium. Nuclear pseudostratification and mucin vacuoles are present. Case 4 - Figure 3 Mucinous proliferation in myometrium. No definite invasion is seen. Case 4 - Figure 4 High-power view of prior figures showing minimal cytologic atypia. Case 4 - Figure 5 High-power view of prior figures showing minimal cytologic atypia. Case 4 - Figure 6 Mucinous proliferation in endocervix. No definite invasion is seen. Case 4 - Figure 7 High-power view of Figure 6. Case 4 - Figure 8 Minimal cytologic atypia in the endocervical proliferation. Case 4 - Figure 9 Appendix (low magnification) Case 4 - Figure 10 Appendix with low grade mucinous lesion Case 4 - Figure 11 Appendix (high magnification) Case 4 - Figure 12 CK7 (appendix) Case 4 - Figure 13 CK20 (appendix) Case 4 - Figure 14 CK7 (endometrium) Note positive internal control Case 4 - Figure 15 CK20 (endometrium) Case 5 - Click here for Text and References Submitted by: Scott Owens - University of Michigan, Ann Arbor, MI Clinical Summary: A 62-year-old man presented with perianal pruritis. On physical examination, he was found to have a perianal rash with areas of excoriation and ulcers. There was no other significant medical history and the patient was otherwise healthy. Case 5 - Figure 1 Gross image of resected perianal skin, with nodular, raised, ulcerated and excoriated rash. Case 5 - Figure 2 Low-power photomicrograph of perianal skin, in which innumerable infiltrating epithelioid cells with pale cytoplasm are scattered among the squamous cells in a pagetoid fashion. Case 5 - Figure 3 Slightly higher magnification, showing similar cells in the anal squamous epithelium immediately adjacent to the distal rectal mucosa. Case 5 - Figure 4 Medium-power view showing cytology of the malignant cells, including several signet ring-type cells and abundant apoptotic debris. Note predilection of the cells to involve the deeper epithelium. Case 5 - Figure 5 High-power view of malignant cells, showing vacuolated cytoplasm, pleomorphic nuclei with prominent nucleoli, and a mitotic figure at the bottom of the field. Case 5 - Figure 6 CEA immunohistochemical stain, highlighting the pagetoid cells. Case 5 - Figure 7 CK20 immunohistochemical stain. Case 5 - Figure 8 CDX-2 immunohistochemical stain. 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.