Radiology Pathology Conference
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1 Radiology Pathology Conference Nadia F. Yusaf, M.D. PGY-3 1/29/2010 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 1 of 90
2 Case 1 60 year- old man presents with abdominal pain Presentation material is for education purposes only. All rights reserved URMC Radiology Page 2 of 90
3 60 year old man w/ abdominal pain Presentation material is for education purposes only. All rights reserved URMC Radiology Page 3 of 90
4 Differential: Liver Lesions Cyst Abscess Primary neoplasm Metastasis Hemangioma Focal fat Presentation material is for education purposes only. All rights reserved URMC Radiology Page 4 of 90
5 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 5 of 90
6 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 6 of 90
7 Liver Metastases 2nd most commonly involved organ by metastatic disease, after lymph nodes Metastatic disease more common than primary Colon, stomach, breast, lung, and pancreas most common neoplasms to metastasize to the liver in adults Calcified metastases occur with mucinous tumors of the breast, colon, and ovary Neuroblastoma, Wilm s tumor and leukemia are the most common in children The majority of metastases are multiple; only 10% are solitary Presentation material is for education purposes only. All rights reserved URMC Radiology Page 7 of 90
8 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 8 of 90
9 Radiology / Pathology Conference January 2010 Michael S. Facik Donna K. Russell Presentation material is for education purposes only. All rights reserved URMC Radiology Page 9 of 90
10 Liver, Ultrasound-guided FNA: Diff-Quik stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 10 of 90
11 Liver, Ultrasound-guided FNA: Diff-Quik stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 11 of 90
12 Liver Ultrasound-guided FNA: Papanicolaou stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 12 of 90
13 Liver, right lobe, ultrasound- guided fine needle aspiration: Malignant tumor cells present derived from adenocarcinoma. Pancreatic endoscopic ultrasound-guided FNA 18 days prior was positive for malignancy, adenocarcinoma. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 13 of 90
14 Pancreas, endoscopic ultrasound-guided FNA: Diff-Quik stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 14 of 90
15 Pancreas, endoscopic ultrasound-guided FNA: Papanicolaou stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 15 of 90
16 Pancreas, endoscopic ultrasound-guided FNA: Cell block, H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 16 of 90
17 Liver, right lobe, core needle biopsy: Moderately differentiated adenocarcinoma consistent with pancreatic primary. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 17 of 90
18 Liver, right lobe, biopsy: PASD stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 18 of 90
19 Liver, right lobe, biopsy: PASD stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 19 of 90
20 Pancreatic Adenocarcinoma EUS guided FNAs gaining recognition obtain a pathologic diagnosis patients with pancreatic lesions (Advantage of this method detection of smaller lesions due to proximity of the probe) Pancreatic carcinoma ranks 4 th in frequency of cancer deaths in North America #s Adenocarcinomas comprise 80-90% of malignant neoplasms of pancreas Presentation material is for education purposes only. All rights reserved URMC Radiology Page 20 of 90
21 Pancreatic Adenocarcinoma Metastatic to Liver Cancer cells reach the liver through portal vein, hepatic artery, hilar lymphatics or by direct extension Primary tumors of the gallbladder, extrahepatic bile ducts, pancreas and stomach frequently involve the liver by direct extension Presentation material is for education purposes only. All rights reserved URMC Radiology Page 21 of 90
22 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 22 of 90
23 Case 2 69 year-old man with hiccups Presentation material is for education purposes only. All rights reserved URMC Radiology Page 23 of 90
24 69 year old man with hiccups Presentation material is for education purposes only. All rights reserved URMC Radiology Page 24 of 90
25 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 25 of 90
26 Differential: Hypermetabolic Rib Lesion Metastases Multiple myeloma Infection TB Primary neoplasm Benign: osteochondroma Malignant: chondrosarcoma Presentation material is for education purposes only. All rights reserved URMC Radiology Page 26 of 90
27 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 27 of 90
28 Rib, left, 6 th, CT-guided FNA: Diff-Quik stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 28 of 90
29 Rib, left, 6 th, CT-guided FNA: Diff-Quik stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 29 of 90
30 Rib, left, 6 th, CT-guided FNA: Papanicolaou stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 30 of 90
31 Rib, left, 6 th, CT-guided FNA: Papanicolaou stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 31 of 90
32 Rib, left, 6 th, CT-guided FNA: Cell Block, H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 32 of 90
33 Rib, left, 6 th, CT-guided FNA: Cell block, H & E stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 33 of 90
34 Rib, left, 6 th, CT-guided fine needle aspiration: Malignant tumor cells present derived from adenocarcinoma. Cell block and cytologic preparations examined. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 34 of 90
35 Esophagus, at 28 cm., biopsy: Invasive adenocarcinoma, superficial biopsy. Comment: Depth of invasion cannot be assessed with this small biopsy. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 35 of 90
36 Esophagus, at 28 cm., biopsy: H & E stain, 10x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 36 of 90
37 Metastatic Adenocarcinoma Metastatic carcinoma prior clinical history is extremely important Compare surgical pathology with cytopathology specimen Presentation material is for education purposes only. All rights reserved URMC Radiology Page 37 of 90
38 Metastatic Esophageal Adenocarcinoma Patient s s with Barrett s s esophagus relative risk of adenocarcinoma fold in comparison with patient s s without Smoking factor risk related to quantity and duration Abdominal obesity risk factor, especially in men Time of diagnosis ~50% of patient s s have distant metastatic disease Presentation material is for education purposes only. All rights reserved URMC Radiology Page 38 of 90
39 Case 3 70 year-old smoker with shortness of breath. History of rheumatoid arthritis. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 39 of 90
40 70 year old smoker w/ SOB. Hx RA Presentation material is for education purposes only. All rights reserved URMC Radiology Page 40 of 90
41 Differential: Solitary Pulmonary Nodule Neoplasm Bronchogenic carcinoma Hamartoma Bronchial adenoma Infection Septic embolus Round pneumonia Abscess granuloma CVD Rheumatoid lung Congenital Sequestration Bronchogenic cyst Miscellaneous Rounded atelectasis Presentation material is for education purposes only. All rights reserved URMC Radiology Page 41 of 90
42 Fleischner Society Recommendations Presentation material is for education purposes only. All rights reserved URMC Radiology Page 42 of 90
43 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 43 of 90
44 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 44 of 90
45 Lung, left, CT-guided FNA: Diff-Quik stain, 42x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 45 of 90
46 Lung, left, CT-guided FNA: Diff-Quik stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 46 of 90
47 Lung, left, CT-guided Presentation material is for education purposes only. All rights reserved URMC Radiology FNA: Papanicolaou stain, Page 4720x of 90
48 Lung, left, CT-guided FNA: Papanicolaou stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 48 of 90
49 Lung, left, Cell Block: Mucin stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 49 of 90
50 Lung, left, CT-guided fine needle aspiration: Malignant tumor cells present derived from squamous cell carcinoma. Cell block and cytologic preparations examined. Comment: Immunohistochemical stains are positive for CK 5/6 and p63, negative for TTF-1 and napsin A. Mucin histochemical stain is negative. The results support the diagnosis of squamous cell carcinoma. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 50 of 90
51 Squamous Cell Carcinoma of Lung Lung cancer leading cause cancer deaths in men and women in U.S. and world Squamous cell carcinoma 2 nd most common type of lung Ca (30%) Risk factors include tobacco use, asbestos, TB, COPD, radon and second hand smoke exposure Presentation material is for education purposes only. All rights reserved URMC Radiology Page 51 of 90
52 Almost there Presentation material is for education purposes only. All rights reserved URMC Radiology Page 52 of 90
53 Case 4 45 year-old man with chest discomfort. History of rib resection in 2006 secondary to chondrosarcoma. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 53 of 90
54 45 year old w/ chest discomfort. Hx of chondrosarcoma T1 fat sat T1 fat sat w/ c Presentation material is for education purposes only. All rights reserved URMC Radiology T2 fat sat Page 54 of 90
55 Differential: Cystic Chest Wall Lesion Recurrent chondrosarcoma Abscess Seroma Hematoma Lymphocele Presentation material is for education purposes only. All rights reserved URMC Radiology Page 55 of 90
56 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 56 of 90
57 Chest, left anterior, CT-guided FNA: Diff-Quik stain, 10x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 57 of 90
58 Chest, left anterior, CT-guided FNA: Diff-Quik stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 58 of 90
59 Chest, left anterior, CT-guided FNA: Papanicolaou stain, 10x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 59 of 90
60 Chest, left anterior, CT-guided FNA: Papanicolaou stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 60 of 90
61 Chest, left anterior, CT-guided FNA: Cell Block, H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 61 of 90
62 Chest, left anterior, CT-guided FNA: Cell Block, H & E stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 62 of 90
63 Chest, left anterior, CT-guided fine needle aspiration: Chondrosarcoma (metastatic/recurrent), Grade II; with marked necrosis. Cell block and cytologic preparations examined. Comment: The specimen consists of malignant chondrocytes, some with double nuclei, in a chondroid matrix background. Approximately 50% of the tumor cells are non-viable (necrotic). Due to the location of the tumor, clinical correlation is recommended to determine whether this is metastatic or recurrent disease. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 63 of 90
64 Lung, right lower lobe, wedge resection and partial lobectomy: Metastatic chondrosarcoma, Grade II. Patient s s history includes chondrosarcoma involving left clavicle with invasion of skeletal muscle, 3.5 cm in largest dimension (6 years ago). Four years ago patient presented with chondrosarcoma, intermediate nuclear grade in left neck resection.. The mass was 5.5 cm with lymphovascular invasion. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 64 of 90
65 Lung, right lower lobe, wedge resection: H & E stain, 10x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 65 of 90
66 Lung, right lower lobe, wedge resection: H & E stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 66 of 90
67 Neck, left resection: H & E stain, 10x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 67 of 90
68 Neck, left resection: H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 68 of 90
69 Chondrosarcoma Arise mostly in bone, less often soft tissue Produce a chondroid matrix rather than osteoid or bone Tumors are aggressive and destructive Graded I III, important in treatment and prognosis Presentation material is for education purposes only. All rights reserved URMC Radiology Page 69 of 90
70 Case 5 65 year-old man presents with abdominal pain Presentation material is for education purposes only. All rights reserved URMC Radiology Page 70 of 90
71 T2 fat sat T1 fat sat Presentation material is for education purposes only. All rights reserved URMC Radiology T1 fat sat w/ c Page 71 of 90
72 Differential: Solid lesions of the pancreas Adenocarcinoma Chronic pancreatitis Neuroendocrine tumor Metastases Lymphoma Presentation material is for education purposes only. All rights reserved URMC Radiology Page 72 of 90
73 Octreotide Scan Indium 111 labeled pentetreotide aka Octreoscan Binds somatostatin receptors, which are found in many neuroendocrine tumors Normal uptake in thyroid, liver, gallbladder, spleen, kidneys and bladder 5 different subtypes of somatostatin receptors w/ various expression of these receptors on tumors Presentation material is for education purposes only. All rights reserved URMC Radiology Page 73 of 90
74 Site of Origin GI Pancreas Adrenal Medulla Pituitary Lung CNS Tumor Carcinoid Islet cell carcinoma: Gastrinoma Glucagonoma Insulinoma VIPoma Pheochromocytoma Pituitary adenoma Small cell carcinoma Paraganglioma Sensitivity (%) Presentation material is for education purposes only. All rights reserved URMC Radiology Page 74 of 90
75 Liver, ultrasound-guided FNA: Diff-Quik stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 75 of 90
76 Liver, ultrasound-guided FNA: Papanicolaou stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 76 of 90
77 Liver, ultrasound-guided FNA: Papanicolaou stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 77 of 90
78 Liver, ultrasound-guided FNA: Papanicolaou stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 78 of 90
79 Liver, ultrasound-guided FNA, Cell Presentation Block, material is for H education & purposes E stain, only. All rights 10x reserved URMC Radiology Page 79 of 90
80 Liver, ultrasound-guided FNA, Cell Block, H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 80 of 90
81 Liver, ultrasound-guided fine needle aspiration: Cellular evidence of neuroendocrine neoplasm. Cell block and cytologic preparations examined. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 81 of 90
82 Liver, left lobe, core needle biopsy: Well-differentiated neuroendocrine carcinoma. Comment: The neoplasm is strongly positive for synaptophysin supporting a neuroendocrine derivation. In view of the history of pancreatic mass, the carcinoma is consistent with a metastasis from pancreatic endocrine tumor. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 82 of 90
83 Liver, left lobe, core needle biopsy: H & E stain, 10x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 83 of 90
84 Liver, left lobe, core needle biopsy: H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 84 of 90
85 Liver, left lobe, core needle biopsy: Presentation material is for education purposes only. All rights reserved URMC Radiology Synaptophysin stain, 10x Page 85 of 90
86 Pancreatic endocrine tumor Tumors of endocrine pancreas arise from stem cells located within the ductal epithelium of the exocrine pancreas < 5% of all pancreatic neoplasms Commonly located in body or tail Slow-growing tumors, most are solitary Most tumors occur in adults Presentation material is for education purposes only. All rights reserved URMC Radiology Page 86 of 90
87 Pancreatic endocrine tumor Tumors occur in sporadic form or as part of multiple endocrine neoplasia (MEN)1 syndrome Prognosis of patients with pancreatic endocrine tumors is predicted with presence or absence of liver metastases Presentation material is for education purposes only. All rights reserved URMC Radiology Page 87 of 90
88 Just in case Patrick Swayze- pancreatic adenocarcinoma Humphrey Bogart- esophageal carcinoma Peter Jennings- bronchogenic carcinoma Ted Kennedy Jr.- chondrosarcoma Steve Jobs- neuroendocrine tumor of the pancreas Presentation material is for education purposes only. All rights reserved URMC Radiology Page 88 of 90
89 References Covidien. Clinical Atlas of Imaging Applications: Octreoscan Emedicine Ziessman, H. et. al. The Requisites: Nuclear Medicine Presentation material is for education purposes only. All rights reserved URMC Radiology Page 89 of 90
90 Thanks for your attention! Presentation material is for education purposes only. All rights reserved URMC Radiology Page 90 of 90
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