—  SPECIALTY CONFERENCE HANDOUT  — Cytopathology Wednesday, March 24, 2010, 7:30 PM Salon 3 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 Diagnostic Challenges in Cytopathology - The Case I'll Remember for the Rest of My Life Moderator: EVA WOJCIK Loyola University Medical Center Maywood, IL 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: BARBARA ANN CENTENO, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL CLAIRE W. MICHAEL, University of Michigan, Ann Arbor, MI EDMUND S. CIBAS, Brigham & Women's Hospital, Boston, MA SAVITRI KRISHNAMURTHYO, MD Anderson Cancer Center, Houston, TX GLADWYN LEIMAN, Fletcher Allen Health Care, University of Vermont, Burlington, VT 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 - Click here for Text and References Submitted by: Barbara Ann Centeno, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL Clinical Summary: The patient was a 49 year old female who was found to have a hard, irregular, mobile mass in her right breast that had recently increased to 4.5 cm in size. Mammogram showed an oval mass with well-circumscribed borders and coarse, heterogenous calcifcations in the subareolar region of the right breast. She had experienced a fall two-three months prior which injured the right breast. Her past medical history was significant for invasive cervical cancer treated with chemotherapy and radiation 6 years prior to the discovery of this mass. A fine needle aspiration was performed using palpation. Case 1 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 1 - Figure 1 Groups of ductal type epithelial cells with balls of myxoid material, Diff-Quik 40X Case 1 - Figure 2 Dense, pinkish stroma with frayed edges Papanicolaou 40X Case 1 - Figure 3 large sheet of ductal epithelium with crowding and overlapping, nuclear enlargement, anisonucleosis and adjacent myxoid stroma, Papanicolaou 40X Case 1 - Figure 4 Enlarged atypical nuclei with nucleoli, Papanicolaou 60X Case 1 - Figure 5 single plasmacytoid, and elongated spindled cells in dense myxoid stroma, Papanicolaou 40X Case 1 - Figure 6 Cytospin showing group of cells with cytological atypia, Papanicolaou 60X Case 1 - Figure 7 Low power image of resection specimen showing nests of epithelial cells in a Myxoid and chondroid matrix, H&E 4X Case 1 - Figure 8 In areas, the chondroid matrix has undergone osseus metaplasia, H&E 4X Case 1 - Figure 9 The neoplastic cells form tubules. The cells have abundant eosinophilic cytoplasm, anisonucleosis, variations in the nuclear membrane, and prominent nucleoli. H&E 40X. Case 1 - Figure 10 Some areas of the neoplasm were more cellular. The nuclear and cytoplasmic features of the neoplastic cells are evident. The associated stroma is bubbly H&E 40X Case 2 - Click here for Text and References Submitted by: Claire W. Michael, University of Michigan, Ann Arbor, MI Clinical Summary: Thocacocentesis fluid submitted from a 63 years old man presenting with recurrent effusion. Chest x-ray and CT Scan with and without contrast showed large left pleural effusion. the lungs were clear and no pleural thickening or nodularities were noted. Case 2 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 2 - Figure 1 Pleural effusion exhibiting high cellularity and wide range of cellular size. Some cells are gigantic with enlaged nuclei, prominent nucleoli and have moderate to abundant cytoplasm. Case 2 - Figure 2 Notice the varaiation in size and the large single or multinucleated cells approaching the size of adjacent morules. Case 2 - Figure 3 Histologic section of the pleura showing surface mesothelium changes Case 2 - Figure 4 Histologic section showing microscopic submesothelial foci of invasion. Case 2 - Figure 5 Histologic section showing microscopic foci of invading mesothelial cords. Case 3 - Click here for Text and References Submitted by: Edmund S. Cibas, Brigham & Women's Hospital, Boston, MA Clinical Summary: 31 year old man with longstanding juvenile rheumatoid arthritis and chronic renal failure. Now with diffuse enlargement of the thyroid. Thyroid FNA (all images: Papanicolaou-stained smear). Case 3 - Figure 1 The smears contained several chunks of dense orange-red material with irregular edges. Case 3 - Figure 2 Another field shows two additional chunks of dense orange-red material with irregular edges. Case 3 - Figure 3 High magnification reveals dense, hyaline material with embedded elongated nuclei. Case 3 - Figure 4 Some fragments appear acellular. Case 3 - Figure 5 Other fragments contain occasional stretched and distorted nuclei. Case 3 - Figure 6 Some fragments contain more numerous nuclei. Aside from their occasionally distorted appearance, the nuclei lack atypia. Case 3 - Figure 7 A Congo red stain on the smear shows apple- green birefringence under polarized light. Case 3 - Figure 8 An autopsy 3 years later revealed an enlarged thyroid gland with extensive interfollicualr and parafollicular amyloid deposition. Case 3 - Figure 9 The elongated nuclei seen on FNA correspond to the nuclei of fibroblasts and endothelial cells entrapped in amyloid deposits. Case 4 - Click here for Text and References Submitted by: Savitri Krishnamurthy, MD Anderson Cancer Center, Houston, TX Clinical Summary: An 85 year old gentleman with chief complaints of left sided chest pain and breathlessness of gradual onset. In addition, he also gave the history of weight loss (17lb), anorexia and dyschezia. He had been a 50 pack a year cigarette smoker in the past. He underwent carolid endarterectomy, hernia repair, and removal of small skin lesions in the past. Chest X-ray revealed a right lower lobe lung mass measuring 3.0cm in maximum dimension. Subsequently, CT scan showed in addition a 2.5cm right adrenal mass. The patient was referred for further evaluation of the lung and adrenal mass. Fine needle aspiration (FNA) of the adrenal mass was performed. Direct smears of FNA of the adrenal mass are provided. 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 The tumor cells are negative for pancytokeratin. The adrenal cortical cells interspersed amidst the tumor cells in the tissue section show positive staining. Case 4 - Figure 10 The tumor cells are uniformly and strongly positive for Melan A(A103) and demonstrate the characteristic coarse and granular cytoplasmic positivity for this marker. Case 4 - Figure 11 S-100 immunostain shows rare positively stained tumor cells. Case 4 - Figure 12 The tumor cells are negative for inhibin. Case 4 - Figure 13 The S-100 immunostain performed on the cell block shows diffuse positivity in almost all of the tumor cells. Case 5 - Click here for Text and References Submitted by: Gladwyn Leiman, Fletcher Allen Health Care, University of Vermont, Burlington, VT Clinical Summary: 57 year old man with 4cm heterogeneous mass in the tail of the pancreas; FNA performed under endoscopic ultrasound guidance. Case 5 - Figure 1 Low power view of dispersed cells with rare tumor giant cells (Papanicolaou stain). Case 5 - Figure 2 Medium power emphasizing small cell size and multinucleated giant cells (Papanicolaou stain) Case 5 - Figure 3 At high magnification, note bland chromatin in mononuclear cells (Papanicolaou stain) Case 5 - Figure 4 Low power view emphasizing areas with good cellular cohesion (Giemsa stain) Case 5 - Figure 5 High power of airdried slide demonstrating small nuclear size compared iewth rbc's (Giemsa stain) Case 5 - Figure 6 Medium magnification displaying vascular association of monotonous tumor cells (Papanicolaou stain) Case 5 - Figure 7 Area of neplastic cells surrounding hint of amorphous material (Papanicolaou stain) Case 5 - Figure 8 High power view of central core of tumor cell mass (Papanicolaou stain) Case 5 - Figure 9 Air-dried slide showing complex vascular core (Giemsa stain) Case 5 - Figure 10 Beta-catenin immunostaining of FNA slide Case 5 - Figure 11 Surgical resection specimen shoeing classic features of solid pseudopapillary neoplasm of pancreas (H&E stain) 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.