—  SPECIALTY CONFERENCE  — Surgical Pathology Monday, March 22, 2010, 7:30 PM Salon 2 Surprises and New Twists in Surgical Pathology Moderator: HENRY D. APPELMAN University of Michigan Hospital, Ann Arbor, MI Disclosure: 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. Panelists: 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 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. Case 1 Submitted by: Lynne Abruzzo - M.D. Anderson Cancer Center, Houston, TX Clinical Summary: 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. Case 1 - Figure 1 Case 1 - Figure 2 H&E 2X Case 1 - Figure 3 H&E 10X Case 1 - Figure 4 H&E 20X Case 1 - Figure 5 H&E 2X Case 1 - Figure 6 H&E 10X Case 1 - Figure 7 H&E 20X Case 2 Submitted by: Jonathan B. McHugh - University of Michigan, Ann Arbor, MI Clinical Summary: 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 Case 2 - Figure 2 Case 2 - Figure 3 Case 2 - Figure 4 Case 2 - Figure 5 Case 2 - Figure 6 pancytokeratin Case 2 - Figure 7 S100 protein Case 2 - Figure 8 p63 Case 2 - Figure 9 calponin Case 2 - Figure 10 Case 3 Submitted by: Anna-Luise Katzenstein - SUNY Upstate Medical Center, Syracuse, NY Clinical History: 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 Click to view with ImageScope Click to view with a Web-Based Viewer Case 3 - Figure 1 Case 3 - Figure 2 Case 3 - Figure 3 Case 3 - Figure 4 Case 4 Submitted by: Cyril Fisher - Royal Marsden Hospital, London, UK Clinical Summary: 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 Case 4 - Figure 2 Case 4 - Figure 3 Case 4 - Figure 4 Case 4 - Figure 5 Case 4 - Figure 6 Case 4 - Figure 7 Case 4 - Figure 8 Case 4 - Figure 9 Case 4 - Figure 10 Case 5 Submitted by: Barbara McKenna - University of Michigan, Ann Arbor, MI Clinical Summary: 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. Case 5 - Figure 1 Case 5 - Figure 2 Case 5 - Figure 3 Handouts for all Specialty Conferences will be accessible via the "Educational Materials" section on the homepage the morning after each respective conference. Printed copies of the handout will not be available at the meeting.