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Surgical Pathology
Monday, March 22, 2010, 7:30 PM
Salon 2
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
Surprises and New Twists in Surgical Pathology
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Moderator:
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HENRY D. APPELMAN
University of Michigan Hospital, Ann Arbor, MI
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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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LYNNE ABRUZZO, M.D. Anderson Cancer Center, Houston, TX
JONATHAN B. MCHUGH, University of Michigan, Ann Arbor, MI
ANNA-LUISE KATZENSTEIN, SUNY Upstate Medical Center, Syracuse, NY
CYRIL FISHER, Royal Marsden Hospital, London, UK
BARBARA MCKENNA, University of Michigan, Ann Arbor, MI
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Clinical histories are displayed below.
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for Text and References
Submitted by: Lynne Abruzzo - M.D. Anderson Cancer Center, Houston, TX
A 62-year-old woman was found to have elevated liver function tests on routine examination. She was otherwise well and her physical examination was unremarkable; she had no peripheral lymphadenopathy, palpable hepatosplenomegaly, or abdominal masses. Magnetic resonance imaging scan demonstrated a 5-cm mass in the left lateral segment of the liver. A needle biopsy of the mass was reported to show a periportal and parenchymal infiltrate composed of small lymphocytes, as well as fatty change. She underwent hepatic lobectomy three months after presentation. Following surgery, the patient declined to undergo a bone marrow biopsy and aspirate. Gastric endoscopy with biopsy performed 6 months later demonstrated chronic active gastritis with Helicobacter pylori, but no evidence of malignant lymphoma. The patient's past medical history was significant for autoimmune hemolytic anemia 12 years earlier, treated with splenectomy and blood transfusions, and toxic multinodular goiter 20 years earlier, treated with 135I.
During the month after presentation, laboratory examinations demonstrated the following: aspartate aminotransferase, 73 U/L (normal, 8-42 U/L); alanine aminotransferase, 71 U/L (normal, 1-55 U/L); alkaline phosphatase, 108 U/L (normal, 37-107 U/L); lactate dehydrogenase, 207 U/L (normal, 94-172 U/L); gamma-glutamyl transferase, 130 U/L (normal, 8-69 U/L); indirect bilirubin, 0.2 mg/dL (normal, 0.2-0.8 mg/dL); erythrocyte sedimentation rate, 58 mm/hr (normal, 0-20 mm/hr); and alpha-fetoprotein, 2.6 ng/mL (normal, 0-15 ng/mL). A complete blood count demonstrated slight anemia, hematocrit, 36.7% (normal, 38.0-47.0%) and thrombocytosis, platelet count, 465 x 109/L (normal, 150-450 x 109/L), with a normal white blood cell count. Serologic studies for rheumatoid factor antibodies, antinuclear antibodies, anti-smooth muscle antibodies, antimitochondrial antibodies, and hepatitis A, B, and C antigens were negative. At the time of the lobectomy, the antimitochondrial antibody titer was 1:160.
for Text and References
Submitted by: Jonathan B. McHugh - University of Michigan, Ann Arbor, MI
A 48-year-old female presented with a 3 cm submucosal mass
arising in the right retromolar trigone region. The
patient stated that 6-7 years ago she noticed “excess
tissue” behind her right lower teeth. Her primary care
physician (PCP) evaluated this area and felt it represented
inflamed salivary gland (about 1 cm at the time).
Approximately one year prior to presentation at our
institution, she noticed a new tender lump in the right
submandibular area. These areas continued to be observed
by her PCP and no changes were noted in the submandibular
region mass, however, the retromolar trigone mass was
enlarging. Therefore, she was referred to our institution
for further evaluation. A biopsy of the retromolar trigone
mass was performed followed by composite resection with
cervical lymph node dissection.
Case 2 - Figure 1
Low power image demonstrating infiltrative growth with extension into adipose tissue. |
Case 2 - Figure 2
Solid growth (left) and tubule formation (upper right) are present in areas. |
Case 2 - Figure 3
Multifocal intracystic papillary growth is present. |
Case 2 - Figure 4
Cribriform growth architecture is also present with round intratumoral cylinders containing basophilic extracellular matrix. |
Case 2 - Figure 5
Although the tumor is architecturally varied, the cells are remarkably uniform with cleared chromatin and nuclear contour irregularity imparting a "papillary thyroid carcinoma-like" appearance. |
Case 2 - Figure 6
The tumor cells are diffusely and strongly positive with pancytokeratin.
pancytokeratin |
Case 2 - Figure 7
S100 protein is strongly positive in both the nuclear and cytoplasmic compartments.
S100 protein |
Case 2 - Figure 8
p63 highlights a subset of tumor cells with some staining strongly and others less intensely.
p63 |
Case 2 - Figure 9
Calponin (and other myoid markers) stain is negative.
calponin |
Case 2 - Figure 10
Lymph node with metastatic adenocarcinoma identical to the retromolar trigone primary. |
for Text and References
Submitted by: Anna-Luise Katzenstein - SUNY Upstate Medical Center, Syracuse, NY
This 46 year old woman complained of intermittent chest
pain, cough, and a 10 pound weight loss over two months.
She was thought to have a right upper lobe pneumonia, and
she was treated with antibiotics. There was no response
after 10 days, and a subsequent chest CT showed a large, 8
cm mass in the right upper lobe. Additionally, there were
several smaller, 5-6 mm nodular masses in the left upper,
right upper and right lower lobes. Core biopsy of the
large mass showed a poorly differentiated squamous cell
carcinoma. A core biopsy was also taken from a separate
5mm nodule in the right lower lobe, and the slide
presented is from that lesion.
Case 3 - Slide 1
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Case 3 - Figure 1
Low magnification view showing partial replacement of a portion of lung parenchyma by a well- demarcated process containing extensive central hyalinization. The adjacent lung is normal. |
Case 3 - Figure 2
Higher magnification shows the collagenous appearance of the central portion of the lesion while highlighting the cellular peripheral portion. Although the lung architecture is effaced in the central areas, the lesion fills alveolar spaces at the periphery leaving adjacent alveolar septa intact. |
Case 3 - Figure 3
High magnification of the central portion of the lesion showing deposition of amorphous, eosinophilic material containing almost no cells. |
Case 3 - Figure 4
High magnification of the cellular peripheral areas showing the characteristic spindle to epithelioid cells with moderate eosinophilic cytoplasm embedded in myxochondroid and collagenous stroma. |
Case 3 - Figure 5
Pancytokeratin stain showing positive staining in alveolar pneumocytes surrounding the tumor, but the tumor is negative. |
Case 3 - Figure 6
Strongly positive CD34 staining in tumor cells. |
Case 3 - Figure 7
Strongly positive CD31 staining in tumor cells. |
Case 3 - Figure 8
High magnification of the tumor cells showing epithelioid to spindle cell configeration and prominent eosinophilic cytoplasm. |
for Text and References
Submitted by: Cyril Fisher - Royal Marsden Hospital, London, UK
A 50 year old male with congenital deafness and
abnormalities of upper limb digits was diagnosed in 1997
(aged 38) with focal segmental glomerulonephritis. Immuno-
suppressive treatment was commenced but in 2001 he became
short of breath and was found to have cannon-ball
pulmonary lesions. Biopsy showed Epstein-Barr virus-related
lymphoproliferative disorder in lung,
necessitating reduction of immunosuppression. The lung
lesions resolved but his renal function deteriorated and
he required hemodialysis for which a right upper limb
native brachial arteriovenous (AV) fistula was performed
in 2005. The following year he underwent an ABO
incompatible live donor renal transplant. Intra-
operatively the kidney, donated by his wife, was found to
have a 1cm renal cell cancer. The transplant team
resected the tumor and proceeded with the operation. The
transplanted kidney functioned well and in 2007 the
brachial AV fistula was ligated. One year later he
presented with an eight week history of worsening pain,
swelling and discoloration over the AV fistula site which
failed to resolve on antibiotics for a suspected
infection. A thrombosed aneurysmal portion of the fistula
was excised. Subsequently, a lump grew rapidly at this
site and an excision was performed.
Case 4 - Figure 1
Low magnification shows vessel lumen and wall with tumor. |
Case 4 - Figure 2
The vessel wall is fibrosed around suture material. Irregular foci of infiltrating tumor are seen. |
Case 4 - Figure 3
Foci of discohesive tumor cells adjacent to suture material. |
Case 4 - Figure 4
Tumor cells are intimately related to suture material. Note the epithelioid morphology of the lesional cells. |
Case 4 - Figure 5
Tumor is present both in the vessel wall and in the lumen of dilated vessel. |
Case 4 - Figure 6
A focus of hemorrhagic tumor is seen in soft tissue adjacent to vessel. |
Case 4 - Figure 7
The tumor infiltrates adjacent soft tissue with sheets of polygonal cells lining irregular vascular spaces. |
Case 4 - Figure 8
More solid area of invasive tumor showing minimal space formation. |
Case 4 - Figure 9
The tumor in this area is composed of epithelioid cells with vesicular nuclei, focally prominent nucleoli and mitotic activity. |
Case 4 - Figure 10
This vein is filled with epithelioid tumor cells. Tumor cells also infiltrate adjacent tissue. |
for Text and References
Submitted by: Barbara McKenna - University of Michigan, Ann Arbor, MI
The patient is a 63 year old woman who presented with
symptoms caused by a partially obstructing mass in the
sigmoid colon. A colonoscopic biopsy of the mass was
reportedly "inconclusive for carcinoma". The patient
underwent a proctosigmoidectomy.
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