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Surgical Pathology
Tuesday, March 10, 2009, 7:30 PM
Convention Center Auditorium
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
Surgical Pathology
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Moderator:
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CHRISTOPHER D.M. FLETCHER
Brigham & Women’s Hospital, Boston, MA
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Disclosure:
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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.
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Panelists:
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CHRISTOPHER CRUM, Brigham & Women's Hospital, Boston, MA
JESSE MCKENNEY, Stanford University Medical Center, Palo Alto, CA
ANDREW CHURG, University of British Columbia, Vancouver, Canada
JASON HORNICK, Brigham & Women's Hospital, Boston, MA
GREGORY LAUWERS, Massachusetts General Hospital, Boston, MA
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Clinical histories are displayed below.
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for Text and References
Submitted by: Christopher Crum - Brigham & Women’s Hospital, Boston, MA
A 78 year old woman with a history of invasive ductal breast carcinoma 5 years prior
to presentation with metastasis to the right clavicle 2 years later . She was in good health and undergoing routine radiologic surveillance when a 3cm left adnexal mass was identified on
PET /CT scan, and confirmed to be cystic on ultrasound. Left salpingo-oophorectomy was performed, with omental and retroperitoneal lymph node biopsies. Exam of the left adnexa revealed a grossly unremarkable fallopian tube and an adherent ovarian mass. The omental and lymph node biopsies were negative. The uterus and right adnexa had been removed previously, with a diagnosis of dermoid cyst. The section is from the left ovarian mass.
(Case courtesy of Dr. Ciaran M. Mannion, Hackensack Medical Center, Hackensack, NJ)
Case 1 - Slide 1
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Case 1 - Figure 4
High power image of the ovarian tumor. Note the uniform pattern of supranuclear vacuoles.
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Case 1 - Figure 5
High power image of the ovarian tumor. The cytoplasmic vacuoles were mucicarmine negative and very weakly positive for PAS.
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Case 1 - Figure 6
CK7
CK7 immunostain is diffusely positive in this tumor, supporting a Mullerian origin.
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Case 1 - Figure 7
CK20
CK20 immunostain is heterogenous, which does not support a colon primary but would not exclude an upper gastrointestinal or pancreatic primary.
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Case 1 - Figure 8
CDX2
CDX2 immunostain is heterogenous, which does not support a colon primary but would not exclude an upper gastrointestinal or pancreatic primary.
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Case 1 - Figure 9
SMAD4
SMAD4 immunostain is positive. This is non-diagnostic for a metastatic tumor of the pancreas.
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Case 1 - Figure 10
p16
p16 immunostain is diffuse and strongly positive. This is unusual for a well differentiated endometrioid or mucinous carcinoma and suggests an unusual variant.
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Case 1 - Figure 11
p53
p53 immunostain is diffusely positive. This is unusual for a well differentiated endometrioid or mucinous carcinoma and suggests an unusual variant of non-serous Mullerian carcinoma.
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for Text and References
Submitted by: Jesse K. McKenney - Stanford University Medical Center, Palo Alto, CA
A 32 year old woman presented with abdominal pain. Imaging studies revealed lymphadenopathy in the retroperitoneum and mediastinum and a calcified renal "cyst". A
core biopsy of the retroperitoneal adenopathy was performed as well as a subsequent partial nephrectomy.
Case 2 - Slide 1
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Case 2 - Figure 1
Needle core biopsy of retroperitoneal lymph node. Neoplasm with nested architecture and eosinophilic granular cytoplasm
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Case 2 - Figure 2
Needle core biopsy of retroperitoneal lymph node. Associated psammomatous calcifications.
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Case 2 - Figure 3
Partial nephrectomy. Gross photograph of ossified renal mass.
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Case 2 - Figure 4
Partial nephrectomy. Over 95% of the tumor was ossified with no viable neoplastic cells.
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Case 2 - Figure 5
Partial nephrectomy. Low power: Small islands of neoplastic cells within the ossified mass.
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Case 2 - Figure 6
Partial nephrectomy. Intermediate power: Small islands of neoplastic cells with nested architecture and eosinophilic granular cytoplasm, identical to original lymph node metastases.
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Case 2 - Figure 7
Partial nephrectomy. High power: Neoplastic cells with prominent nested architecture and eosinophilic granular cytoplasm.
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for Text and References
Submitted by: Andrew Churg - University of British Columbia, Vancouver, Canada
67 year old male with a 2-3 year history of a scrotal mass, initially thought to be associated with the epididymis, but actually found at surgery to be in a hydrocoele. The hydrocoele was resected. The tumor measured approximately 2 cm across and appeared to be a solitary lesion both grossly and microscopically.
Case 3 - Slide 1
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for Text and References
Submitted by: Jason L. Hornick - Brigham & Women’s Hospital, Boston, MA
A 60 year-old female presented to her primary care physician complaining of a painless "bulge" in the mid abdomen. A CT scan revealed a well-circumscribed mass in the body of the pancreas, around which the pancreatic duct deviated. Endoscopic ultrasound showed a 3 cm round, hypoechoic, solid mass in the body of the pancreas at the junction with the tail, with no enlarged lymph nodes. A distal pancreatectomy was performed.
Case 4 - Slide 1
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Case 4 - Figure 1
Gross photograph showing a well-circumscribed tumor within the body of the pancreas.
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Case 4 - Figure 2
The tumor is sharply demarcated from the surrounding pancreatic parenchyma.
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Case 4 - Figure 3
The tumor is composed of cells with abundant clear cytoplasm. Note the thin fibrous pseudocapsule surrounding the tumor.
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Case 4 - Figure 4
The tumor shows a mixture of spindle cell (left) and epithelioid (right) cytomorphology.
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Case 4 - Figure 5
Spindle cells with granular eosinophilic to clear cytoplasm. Note the focal areas of stromal hyalinization (bottom).
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Case 4 - Figure 6
In areas, the tumor shows a well-developed fascicular architecture, mimicking a smooth muscle neoplasm.
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Case 4 - Figure 7
A more sheet-like area of the tumor. Note the focal perivascular growth pattern (center).
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Case 4 - Figure 8
Tumor cells with abundant clear cytoplasm and distinct cell borders, focally associated with blood vessel walls.
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Case 4 - Figure 9
Spindle cells with granular eosinophilic cytoplasm. Note the uniform nuclei with fine chromatin and small nucleoli.
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Case 4 - Figure 10
Polygonal cells with clear to eosinophilic cytoplasm. Occasional multinucleated cells and focal pleomorphism are present.
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for Text and References
Submitted by: Gregory Y. Lauwers - Massachusetts General Hospital, Boston, MA
The clinical history of this patient, a 63-year-old male, actually starts 12 months before the biopsy material available for review was sent to pathology. In the winter of 2007, this previously healthy male presented with 3 months history of rectal bleeding, abdominal cramping and weight loss. He was eventually diagnosed and operated for a 5 cm colonic adenocarcinoma (pT2N1M0). Adjuvant therapy was started using a combination of FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) and Avastin® (bevacizumab). However, 10 months post-operatively, he was diagnosed with multiple liver metastases involving both hepatic lobes for which he received FOLFIRI (5-fluorouracil, leucovorin, and irinotecan) and Avastin®. Interventional radiologic therapy was later attempted as well. Subsequently, the patient complained of belching, heartburn, and nausea. Eventually, after the symptoms waxed and waned for 2 months, an upper endoscopy was performed and demonstrated a diffusely erythematous and friable duodenal and gastric antral mucosa. Biopsies were performed.
Case 5 - Slide 1
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Case 5 - Figure 1
Endoscopic picture: the mucosa is diffusely erythematous.
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Case 5 - Figure 2
The eroded mucosa displays moderate expansion of the lamina propria by mixed inflammatory infiltrate. The loss of glandular elements with withering epithelial elements is obvious.
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Case 5 - Figure 3
Residual basal glandular elements with atypical epithelial cells are observed. Note the numerous eosinophils throughout the lamina propria. Distended capillaries with plump endothelial cells are present.
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Case 5 - Figure 4
Higher magnification of glandular cystic dilatation with epithelial flattening, reactive atypia and apoptosis.
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Case 5 - Figure 5
Clustered yttrium-90 microspheres were noted extruded into the lamina propria suggesting the diagnosis of yttrium-90 microsphere-induced gastritis after SIRT.
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