|
Hematopathology
Wednesday, March 5, 2008 , 7:30 PM
Convention Center 102/104/106More than Meets the Eye
|
Moderator:
|
MARSHA C. KINNEY
University of Texas Health Science Center
San Antonio, TX
|
|
Disclosure:
|
The speakers have indicated they have nothing to disclose.
|
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.
for Text and References
Submitted by: James R. Cook - Cleveland Clinic, Cleveland, OH
A previously healthy 26 year old man first came to clinical attention for a thyroid nodule. FNA of the thyroid mass was positive for papillary carcinoma, and a total thyroidectomy was scheduled. A pre-operative CBC and peripheral smear review (Figure 1) demonstrated the following results:
CBC 20.65 x103/µL
RBC 4.87 x106/µL
Hgb 15.2 g/dL
HCT 43.7 %
MCV 89.7 fL
PLT 183 x103/µL
Differential:
Abs Neut 2.68 x103/µL
Abs Lymph 4.34 x103/µL
Abs Mono 0.21 x103/µL
Abs Eo 13.42 x103/µL
Abs Baso 0.00 x103/µL
To evaluate the patient's marked eosinophilia, a bone marrow aspirate and biopsy were performed. The bone marrow aspirate (Figures 2, 3 and 4) differential count revealed:
2% Blasts; 3% Promyelos; 45% Myelos/Metas/Bands/Segs; 13% Eos; 0% Basos; 0% Monos; 14% Erythroids; 22% Lymphs; 1% Plasma cells
The bone marrow core biopsy demonstrated a 70% cellular bone marrow with trilineage hematopoiesis and eosinophilia (Figures 5, 6, and 7). No focal lesions were identified in routine sections. Immunohistochemical stains demonstrated mildly increased, scattered tryptase-positive mast cells that appeared spindled with coexpression of CD25 (Figure 8).
Case 1 - Slide 1
|
Case 1 - Figure 1
Peripheral blood smear displaying marked absolute eosinophilia.
|
Case 1 - Figure 2
Bone marrow aspirate smear demonstrating eosinophilia. Eosinophil precursors frequently display coarse basophilic granules.
|
Case 1 - Figure 3
Bone marrow aspirate smear demonstrating eosinophilia. Eosinophil precursors frequently display coarse basophilic granules.
|
Case 1 - Figure 4
Bone marrow aspirate smear demonstrating eosinophilia. Eosinophil precursors frequently display coarse basophilic granules.
|
Case 1 - Figure 5
Low power bone marrow core biopsy. The bone marrow is approximately 70% cellular with trilineage hematopoiesis. Focal lesions are not present.
|
Case 1 - Figure 6
High power bone marrow core biopsy. There is trilineage hematopoiesis with focal areas showing marked eosinophilia.
|
Case 1 - Figure 7
High power bone marrow core biopsy. There is trilineage hematopoiesis with focal areas showing marked eosinophilia.
|
Case 1 - Figure 8
Bone marrow core biopsy. An immunohistochemical stain for mast cell tryptase demonstrates increased, scattered mast cells without aggregates. As shown in the inset, the mast cells appear spindled and appear to coexpress CD25.
|
for Text and References
Submitted by: L. Jeffrey Medeiros - University of Texas, M.D. Anderson Cancer Center, Houston, TX
An 11-year-old girl developed abdominal pain and physical examination revealed enlarged cervical lymph nodes. Biopsy of one lymph node was considered atypical paracortical hyperplasia without a specific diagnosis rendered. Bone marrow examination showed hypercellularity, myeloid hyperplasia, and eosinophilia. The patient was then referred to another hospital.
At time of transfer, the complete blood count showed normal hemoglobin and platelet counts and a leukocyte count of 19,000 with 10% eosinophils. Imaging studies showed cervical and retroperitoneal lymphadenopathy. A second cervical lymph node was biopsied at this time. In retrospect, the initial lymph node biopsy specimen was also involved by the same process. Immunohistochemical studies were performed and a number of markers were assessed with the following results: CD2+, CD4-, CD5+, CD7+, CD8-, Ig-, CD19-, and CD20-. (Additional markers are illustrated.) Conventional cytogenetic analysis was performed previously on bone marrow aspirate material and again on the second cervical lymph node specimen. The results showed a normal karyotype, 46, XX, in both specimens.
Case 2 - Slide 1
|
for Text and References
Submitted by: Ahmet Dogan - Mayo Clinic, Rochester, MN
The patient was a 38 year-old male who was in excellent health until he developed some irritable bowel type symptoms in late 2003. He sought medical attention in July of 2005 because of the peripheral edema that he noted beginning in the spring of 2005. He also noted that he had some progressive shortness of breath over this period of time. CT scans of the abdomen and pelvis and chest and neck were performed. These studies demonstrated splenomegaly (14 cm AP and 18 cm cranial caudal). Also noted were scattered peri-aortic and mesenteric lymph nodes throughout ranging between 5 and 9 mm and bilateral axillary and mediastinal adenopathy with lymph nodes less than 1 cm in diameter.
An axillary lymph node biopsy was performed.
Case 3 - Slide 1
|
Case 3 - Figure 4
High power of the lymphoid follicles (Hematoxylin-eosin)
|
Case 3 - Figure 5
High power of the interfollicular area (Hematoxylin-eosin)
|
Case 3 - Figure 6 - Lambda
Low power view of the lymph node stained for immunoglobulin lambda light chains (Immunoperoxidase)
|
Case 3 - Figure 7 - Kappa
Low power view of the lymph node stained for immunoglobulin kappa light chains (Immunoperoxidase)
|
Case 3 - Figure 8 - IgA
Low power view of the lymph node stained for immunoglobulin alpha heavy chains (Immunoperoxidase)
|
for Text and References
Submitted by: Steven H. Swerdlow - University of Pittsburgh Medical Center, Pittsburgh, PA
An 88-year-old woman who hit her head on the sink when she bent to pick up a brush and developed a lump on her forehead. Initial CT was interpreted as a small left frontal scalp hematoma. She had persistent shoulder/neck pain, went to the ER and her shoulder was injected with steroids and she was given oral steroids as well. After some pain relief, the patient presented again 4 weeks following her injury to the hospital with diplopia, a persistent "hematoma" and severe neck pain. Following a repeat CT and an MR, an excisional biopsy was performed and is submitted for your review. Flow cytometric immunophenotypic studies demonstrated a CD5-, CD10-, CD20+, kappa monoclonal population with admixed heterogeneous T-cells.
Case 4 - Slide 1
|
Case 4 - Figure 1
Note the diffuse proliferation associated with a "starry sky" related to the scattered tingible body macrophages.
|
Case 4 - Figure 2
This high magnification field looks very much like a Burkitt lymphoma with rather uniform intermediate sized transformed lymphocytes and scattered tingible body macrophages.
|
Case 4 - Figure 3
Note how some of the neoplastic cells have very clefted nuclei.
|
Case 4 - Figure 4
Here the neoplastic cells are even more pleomorphic and include a very large multinucleate cell.
|
Case 4 - Figure 5
The Wright-Giemsa stained cytospin shows intermediate to large sized transformed cells with sometimes vacuolated basophilic cytoplasm.
|
Case 4 - Figure 6 - CD3
There are relatively few scattered CD3+ cells.
|
|
|
|
|
Click to view with ImageScope
Click to view with a Web-Based Viewer
