|
Surgical Pathology
Monday, March 3, 2008, 7:30 PM
Convention Center Korbel Ballroom
|
Moderator:
|
CHRISTOPHER FLETCHER
Brigham & Women's Hospital
Boston, MA
|
|
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: Linda Ferrell
A 37 year-old Caucasian woman was admitted with jaundice and asterixis for an expedited transplant evaluation for presumed end-stage liver disease with acute decompensation. The patient's history was remarkable for morbid obesity with a body mass index (BMI) of 59.4 three years ago. She then lost approximately 300 pounds after her Roux-en-Y gastric bypass procedure at a referring institution (no biopsy available for review) over a period of 2 years. Six months prior to this admission, she developed jaundice. She now presented with a BMI of 26.5, height 5'2", 145 pounds. Liver laboratory studies on admission at UCSF included total bilirubin of 28, AST: 105 (mildly elevated), ALT: 39 (normal), alkaline phosphatase: 124 (mildly elevated), low serum albumin, and INR of 2.4 (prolonged). Lipid studies included serum cholesterol: 74, triglycerides:102, LDL:41, HDL:13. HAV, HBV, HCV, and other viral markers (CMV, EBV, HIV) were negative; ANA, SMA, and LKM-1 antibodies were negative; ceruloplasmin and alpha-1-antitrypsin levels were within normal limits. Drug regimen had included omeprazole, spironolactone, Lasix, and lactulose. Ultrasound demonstrated hepatomegaly with fatty change, ascites, and splenomegaly. The patient had no history of diabetes, hypertension, alcohol or drug abuse. Her family history was unremarkable. Sample is from explant, performed 7 days after admission.
Case 1 - Slide 1
|
Case 1 - Figure 1
10x. Portal area upper right, central zonal scar on left, and extensive intrasinusoidal scarring is also present. Inflammation is scant, and ductular reaction is present in lobular zone 1. (10x)
|
Case 1 - Figure 2
Higher magnification (20x). The scar at the bottom of the photo is the residual centrizonal region (zone 3). Ductular metaplasia is present in zone 1 and 2, and ballooned hepatocytes are present near the centrizonal scar. Mild large droplet fat is present.
|
Case 1 - Figure 3
40x. Ballooned hepatocytes and ductular metaplasia. Also note the sinusoidal pattern of scarring. Inflammation is mostly mononuclear but some neutrophils are also present. Focal large droplet fat is present on right.
|
Case 1 - Figure 4
20x. Similar to figure 3, with ballooned hepatocytes, ductular metaplasia. The inflammatory infiltrate is more mixed than in fig 3. Mallory hyaline is present in ballooned hepatocytes (center, bottom center and bottom right).
|
Case 1 - Figure 5
20x. Prominent ballooned hepatocytes, many which contain Mallory hyaline. Also note bile stasis/bile plugs. Metaplastic ductule is present on left.
|
Case 1 - Figure 6
20x. Prominent ballooned hepatocytes, many with Mallory hyaline. Fatty change is scant but present.
|
Case 1 - Figure 7
40x. Centrizonal scar, with adjacent ballooned hepatocyte that contains prominent Mallory hyaline.
|
Case 1 - Figure 8
40x. Zone of prominent cholestasis. Large droplet fat is also present. Note sinusoidal fibrosis.
|
Case 1 - Figure 9
Trichrome stain, 10x. Portal zone at bottom, centrizonal scar at top center. Note sinusoidal/centrizonal pattern of scarring. Fatty change can be identified.
|
Case 1 - Figure 10
Trichrome stain, 10x. Portal zone on left, residual centrizonal area with scar on right. Sinusoidal and centrizonal pattern of scarring is prominent.
|
Case 1 - Figure 11
Trichrome stain, 20x. Central vein with surrounding scar. Pericellular and sinusoidal scarring is prominent.
|
Case 1 - Figure 12
Orcein stain, 20x. Central vein wall is outlined by the dark fibers in the center. The lumen of the vein is sclerosed and occluded.
|
for Text and References
Submitted by: David Elder
Female, 33, Right posterior thigh. "Elevated, purple dome-like skin lesion".
Case 2 - Slide 1
|
Case 2 - Figure 1
Scanning magnification shows a dome-shaped lesion in the skin .
|
Case 2 - Figure 2
At low magnification, thickened collagen bundles and increased cellularity can be appreciated.
|
Case 2 - Figure 3
The lesion extends through much of the thickness of the reticular dermis.
|
Case 2 - Figure 4
The lesion is comprised of uniform cells placed among thickened collagen bundles.
|
Case 2 - Figure 5
The lesional cells are plump spindle cells. A prominent vascular stroma is also appreciated.
|
Case 2 - Figure 6
At higher magnification prominent relatively thick walled vessels are present in association with the infiltrating spindle cells and the thickened collagen bundles.
|
Case 2 - Figure 7
Plump spindle cells infiltrating among thick collagen fibers at the base of the lesion.
|
Case 2 - Figure 8
In another area near the base, lesional cells infiltrate as single cells among more normal collagen fiber bundles. In the upper left, one of the thick walled vessels with plump endothelial cells is appreciated.
|
Case 2 - Figure 9 - S-100
An S100 stain demonstrates strong and diffuse uniform positivity throughout the lesion.
|
Case 2 - Figure 10 - S-100
The plump spindle cells are uniformly and strongly S100 positive.
|
Case 2 - Figure 11 - HMB45
An HMB45 stain demonstrates a rare group of positive cells in the superficial portion of the lesion.
|
Case 2 - Figure 12 - HMB45
The positive cells are strongly stained. A few cells containing pigment, mostly melanophages, are also present along with a sprinkling of lymphocytes.
|
Case 2 - Figure 13 - Actin
An actin stain highlights the vessels which are present throughout the profile of the tumor. Contrast this increased vascularity with the normal vascularity of the adjacent uninvolved reticular dermis.
|
Case 2 - Figure 14 - Actin
The actin strongly stains vessel walls, indicating the presence of pericytes.
|
Case 2 - Figure 15 - FVIIIRAg
A stain for factor VIII highlights the thickened endothelial cells.
|
for Text and References
Submitted by: Ian Ellis
Woman aged 36, Presented with a lump in her left breast. First noticed 2 years previously. Clinically a suspicious 30mm mass. Mammography and ultrasound showed a malignant appearing 28mm speculate mass. Core biopsy showed invasive carcinoma. FNA of axillary node showed malignant cells. Right breast asymptomatic and no abnormality on clinical examination. Mammography showed 38mm of suspicious calcification. Core biopsy showed LCIS with ADH. Initial treatment left mastectomy and right wide local excision. Case material from the right breast specimen.
Case 3 - Slide 1
|
Case 3 - Figure 4
Low and high magnification views of a duct space showing effacement of the normal epithelium by a population of atypical cells arranged in a micropapillary configuration. The features are typical of low to intermediate grade DCIS.
|
Case 3 - Figure 5
Low and high magnification views of a duct spaces an admixture of DCIS with islands of paler cells with the morphology of lobular neoplasia (LCIS).
|
Case 3 - Figure 6
Low and high magnification views of a duct spaces an admixture of DCIS with islands of paler cells with the morphology of lobular neoplasia (LCIS).
|
Case 3 - Figure 7
An expanded lobule adjacent to the tissue illustrated in figure 1-6 showing features typical of lobular carcinoma in situ.
|
Case 3 - Figure 8
More examples of intimately admixed DCIS and LCIS.
|
Case 3 - Figure 9
More examples of intimately admixed DCIS and LCIS.
|
Case 3 - Figure 10
E-Cadherin immunocytochemistry staining shows strong membrane positive reactivity in the DCIS component and negativity in the LCIS component in the pure and admixed areas.
|
Case 3 - Figure 11
E-Cadherin immunocytochemistry staining shows strong membrane positive reactivity in the DCIS component and negativity in the LCIS component in the pure and admixed areas.
|
Case 3 - Figure 12
E-Cadherin immunocytochemistry staining shows strong membrane positive reactivity in the DCIS component and negativity in the LCIS component in the pure and admixed areas.
|
for Text and References
Submitted by: Cheryl Coffin
A 13-month old boy developed a left testicular mass over a period of a few weeks. An ultrasound showed irregularity and vascularity within the mass. Serum alpha-fetoprotein and human chorionic gonadotropin levels were normal. A CT scan of the chest, abdomen, and retroperitoneum showed no evidence of malignancy. A left radical orchiectomy was performed, and subsequently the patient underwent inguinal lymph node biopsy and staging bone marrow biopsies.
Case 4 - Slide 1
|
Case 4 - Figure 1
The paratesticular ectomesenchymoma shows a proliferation of spindle and polygonal cells in sheets and fascicles.
|
Case 4 - Figure 2
The spindle cells are embedded in a myxoid and collagenized background and have elongated eosinophilic cytoplasmic extensions.
|
Case 4 - Figure 3
Mature ganglion cells with eosinophilic cytoplasm are intermingled with spindle cells.
|
Case 4 - Figure 4
The spindle cells have oval to elongated nuclei with granular chromatin, occasional prominent nucleoli and variable amounts of eosinophilic cytoplasm, with a focal strap-like configuration.
|
Case 4 - Figure 5
The mature ganglion cells are intermingled with spindle cells and in some areas the background resembles neuropil.
|
Case 4 - Figure 6 - MYOGENIN
Diffuse nuclear reactivity for myogenin is present in areas of rhabdomyoblastic differentiation.
|
Case 4 - Figure 7 - DESMIN
Diffuse cytoplasmic reactivity for desmin is present in areas of rhabdomyoblastic differentiation.
|
Case 4 - Figure 8 - SYNAPTOPHYSIN
Cytoplasmic reactivity for synaptophysin is present in ganglion cells N
|
for Text and References
Submitted by: Bruce Wenig
A 67 year old female presented with a right neck mass. Work-up revealed a "cold" nodule in the right lobe of the thyroid gland. A fine needle aspiration biopsy was performed with a diagnosis of "atypical follicular lesion, highly suspicious for thyroid papillary carcinoma" with the recommendation for surgical resection of the thyroid lobe with intraoperative evaluation. At the time of surgery, frozen section was performed with a diagnosis of "follicular epithelial cell lesion, defer to permanent sections". A right thyroid lobectomy and isthmusectomy was performed. A well-circumscribed nodule measuring 2.1 cm in greatest dimension was identified in the right lobe of the thyroid gland.
Case 5 - Slide 1
|
Case 5 - Figure 1
Low magnification showing the presence of a well-circumscribed follicular epithelial cell lesion.
|
Case 5 - Figure 2
Slightly higher magnification showing the well-circumscribed follicular epithelial cell lesion within which are scattered areas of apparent increased cellularity.
|
Case 5 - Figure 3
At higher magnification, areas of this lesion show round and regular appearing nuclei with coarse nuclear chromatin.
|
Case 5 - Figure 4
At higher magnification, areas of this lesion show round and regular appearing nuclei with coarse nuclear chromatin.
|
Case 5 - Figure 5
At higher magnification, areas of this lesion show the presence of enlarged nuclei with irregularities in size and shape, dispersed to optical clear appearing nuclear chromatin, nuclear crowding and overlapping, and nuclear grooves.
|
Case 5 - Figure 6
At higher magnification, areas of this lesion show the presence of enlarged nuclei with irregularities in size and shape, dispersed to optical clear appearing nuclear chromatin, nuclear crowding and overlapping, and nuclear grooves.
|
|
|
|
|
Click to view with ImageScope
Click to view with a Web-Based Viewer
