Case 1

submitted by:
David Klimstra
Memorial Sloan Kettering Cancer Center
New York, New York

Clinical Summary:

The patient is a 67 year old female who presented with pneumonia, with only partial resolution following antibiotic treatment. A chest CT scan disclosed a 1.2 cm right lower lobe nodule that was circumscribed and non-calcified. Review of old chest radiographs showed the nodule, which had been stable over at least 6 years. A fine needle aspiration was performed and interpreted as positive for carcinoid tumor. A right lower lobectomy and mediastinal lymph node dissection were performed. Grossly, there was a 1.5 cm red to tan, slightly indurated spherical mass situated 1.4 cm deep to the pleural surface.

Case 1 - Figure 1 - Low power view showing areas of sclerosis separating nests of epithelioid cells. Irregular cavernous spaces contain blood.

Case 1 - Figure 2 - The epithelioid cells contain central, round to oval nuclei. Slit-like spaces are lined by a second cell population consisting of cuboidal, hobnailed cells.

Case 1 - Figure 3 - Higher power shows focal clear cell change in the oval epithelioid cells. The cuboidal cells lining the slit-like spaces resemble type II pneumocytes.

Case 1 - Figure 4 - Immunohistochemical staining for TTF-1 shows positivity in both the oval cells and the cuboidal cells.

Case 2

submitted by:
Claudia Y. Castro
University of Alabama
Birmingham, Alabama

Clinical Summary:

The patient is a 49 year-old Hispanic male who complained of cough for 2 months. His past medical history was significant only for heavy smoking (2 pack of cigarettes /day/ 15 years) . A chest radiograph showed a well-circumscribed nodule in the periphery of the right upper lobe. Patient underwent wedge resection. After frozen section diagnosis, a completion of the lobectomy was performed. The specimen consisted of a wedge biopsy of lung (4.8 x 2.3 x 2.2 cms) containing a relative well circumscribed, 1.4 cms subpleural nodule. The cut surface was white, firm and focally necrotic. The nodule was located at 1.0 cms from the staple surgical resection margin.

Case 2 - Figure 1 - LELC with "Schmicke's pattern" showing neoplastic cells growing diffusely and closely intermingled with inflammatory cells (low power).

Case 2 - Figure 2 - LELC with cells, with ill defined cell border, vesicular nuclei, prominent nucleoli, intermixed with lymphocytes and plasma cells (medium and high power).

Case 2 - Figure 3 - LELC with cells, with ill defined cell border, vesicular nuclei, prominent nucleoli, intermixed with lymphocytes and plasma cells (medium and high power).

Case 2 - Figure 4 - LELC with cells, with ill defined cell border, vesicular nuclei, prominent nucleoli, intermixed with lymphocytes and plasma cells (medium and high power).

Case 2 - Figure 5 - LELC showing strong keratin immunoreactivity in neoplastic cells.

Case 2 - Figure 6 - LELC showing negative LCA in the neoplastic cells, whereas background lymphoid cells are positive.

Case 3

submitted by:
Cheryl M. Coffin
University of Utah
Salt Lake City, Utah

Clinical Summary:

A six-year-old girl had a right lower lobe lung mass. Wedge resection revealed a 2.6x2.5x1.5 cm firm nodule with a grey-white whorled surface.

Case 3 - Figure 1 - Inflammatory myofibroblastic tumor displays interlacing fascicles of spindle cells with a prominent lymphoplasmacytic infiltrate.

Case 3 - Figure 2 - Inflammatory myofibroblastic tumor with myxoid and spindle cell areas.

Case 3 - Figure 3 - Inflammatory myofibroblastic tumor demonstrates spindle cells with elongated nuclei and eosinophilic nucleoli resembling ganglion cells accompanied by a lymphoplasmacytic infiltrate.

Case 4

submitted by:
Jae Y. Ro
Ulsan University College of Medicine
Seoul, Korea

Clinical Summary:

A 70-year-old man who had a history of stroke took a CT scan of the chest demonstrating a 3.0 cm mass in the left lower lobe. A needle biopsy revealed an adenocarcinoma. He had a past history of hypertension, but there was no history of tuberculosis. He was a non-smoker. There was no remarkable family history. His general conditions were good and laboratory findings were within normal limits. Staging procedures including bone scan and MRI of the brain did not reveal metastasis. Left lower lobe lobectomy was performed 1 month after the histologic diagnosis of carcinoma.

Case 4 - Figure 1 - Gross photograph of left lower lobe of lung mass (3.5 cm in greatest dimension).

Case 4 - Figure 2 - Micropapillary formation from the surface of the large tumor glands.

Case 4 - Figure 3 - Micropapillary tufts are lying within retracted connective tissue spaces.

Case 4 - Figure 4 - High power of the micropapillary component.

Case 4 - Figure 5 - TTF-1 and CK7 immunostainings are positive in both the micropapillary and nonmicropapillary components of lung adenocarcinoma.

Case 5

submitted by:
Michael Koss
Keck School of Medicine at USC
Los Angeles, California

Clinical Summary:

The patient is a 63 year-old woman with coronary artery disease who developed a progressive neurologic illness that resembled spinocerebellar ataxia. As her physician thought her neurologic illness may have been a manifestation of a paraneoplastic syndrome, she underwent chest and upper abdomen computed tomography (CT) looking for a primary lung malignancy. The chest CT showed a 2.0-cm in diameter nodule in the left lung apex. Contrast studies suggested it was likely malignant and she had the nodule resected. Sections are from this nodule.

Case 5 - Figure 1 - Low magnification view of the biopsy. It shows a localized, nodular lymphoid lesion that largely replaces the underlying lung architecture. The lesion is unencapsulated and shows mild extension into the surrounding lung around vessels.

Case 5 - Figure 2 - Scattered nodules composed of small lymphocytes are present within the lesion.

Case 5 - Figure 3 - This view shows the edge of a lymphocytic nodule and the intervening parenchyma. The nodule consist of small lymphocytes with round or oval nuclei and scant cytoplasm. The intervening parenchyma shows sheets of plasma cells of mature appearance with intermixed small lymphocytes.

Case 5 - Figure 4 - Another view of the parenchyma between nodules. This shows abundant plasma cells, small lymphocytes, and cuboidal cells (presumably type 2 cells) lining alveolar spaces. At least one of these alveolar lining cells contains an intranuclar inclusion, which can lead to its mistaken identification as a Dutcher body.