Radiology Pathology Conference
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1 Radiology Pathology Conference Sharlin Johnykutty,, MD, Cytopathology Fellow Sara Majewski, MD, Radiology Resident Friday, August 28, 2009 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 1 of 95
2 CASE 1 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 2 of 95
3 * 52-year-old female with bilateral pulmonary nodules with recent chest pain. Differential diagnosis for this cavitary nodule? Presentation material is for education purposes only. All rights reserved URMC Radiology Page 3 of 95
4 CASE 1: Differential Diagnosis for This Lesion Lung Primary - Non-Small Cell Carcinoma/Squamous Cell Carcinoma Infection Septic emboli Fungal TB Metastases Vasculitis/Wegener s Granulomatosis Presentation material is for education purposes only. All rights reserved URMC Radiology Page 4 of 95
5 Intensely hypermetabolic 3 x 2.7 cm spiculated cavitary lesion in left upper lobe lung (SUV up to 16.8). Does this change your differential? Presentation material is for education purposes only. All rights reserved URMC Radiology Page 5 of 95
6 *1.2 x 1.1 cm spiculated hypermetabolic pulmonary nodule in the right lower lobe (SUV 3.9) *Low-grade FDG uptake in a sclerotic lesion in the anterior left fifth rib (SUV 2.9) Presentation material for education purposes only. All rights reserved URMC Radiology Page 6 of 95 Would this change your differential?
7 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 7 of 95
8 Pathology Presentation material is for education purposes only. All rights reserved URMC Radiology Page 8 of 95
9 Case 1 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 9 of 95
10 Lung, left middle lobe, CT-guided FNA: Diff-Quik stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 10 of 95
11 Lung, left middle lobe, CT-guided FNA: Diff-Quik stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 11 of 95
12 Lung, left middle lobe, CT-guided FNA: Presentation material is for education purposes only. All rights reserved URMC Radiology Page 12 of 95 Papanicolaou stain, 40x
13 Lung, left middle lobe, CT-guided FNA: Cell Block, H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 13 of 95
14 Lung, left middle lobe, CT-guided FNA: Cell Block, H & E stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 14 of 95
15 Lung, left middle lobe, CT-guided fine needle aspiration: Malignant tumor cells present derived from poorly differentiated non-small cell carcinoma. Comment: Immunohistochemical stains are positive for p63 and negative for cytokeratin 7 and TTF-1. These findings are consistent with a squamous cell carcinoma. Cell block and cytologic preparations examined. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 15 of 95
16 Lung, left middle lobe, cell block: p63 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 16 of 95
17 Lung, left middle lobe, cell block: TTF-1 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 17 of 95
18 CASE 1: Key Facts about Non- Small Cell Carcinoma Usually solitary pulmonary nodule or mass, often spiculated Can have mediastinal/hilar lymphadenopathy Staging TNM recently revised Presentation material is for education purposes only. All rights reserved URMC Radiology Page 18 of 95
19 CASE 2 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 19 of 95
20 Multiple lytic bone lesions associated with soft tissue masses with additional lesions in vertebral bodies and ribs. Differential diagnosis? Presentation material is for education purposes only. All rights reserved URMC Radiology Page 20 of 95
21 * Same CT slice. Does this narrow your differential diagnosis? 49-year-old male who had excision skin of a skin lesion on his right shoulder in Presentation material is for education purposes only. All rights reserved URMC Radiology Page 21 of 95
22 CASE 2: Differential Diagnosis Metastases Lung Renal Thyroid Melanoma Multiple Myeloma Atypical Lymphoma Rarely atypical infection TB Syphillis Presentation material is for education purposes only. All rights reserved URMC Radiology Page 22 of 95
23 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 23 of 95
24 Pathology Presentation material is for education purposes only. All rights reserved URMC Radiology Page 24 of 95
25 Case 2 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 25 of 95
26 Bone, iliac, left, CT-guided FNA: Diff-Quik stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 26 of 95
27 Bone, iliac, left, CT-guided FNA: Diff-Quik stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 27 of 95
28 Bone, iliac, left, CT-guided FNA: Papanicolaou stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 28 of 95
29 Bone, iliac, left, CT-guided FNA: Papanicolaou stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 29 of 95
30 Bone, iliac, left, cell block: Hematoxylin and eosin stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 30 of 95 Cell block: 40x
31 Bone, iliac, left, cell block: HMB45 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 31 of 95
32 Bone, iliac, left, cell block: S-100 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 32 of 95
33 Bone, iliac, left, CT-guided fine needle aspiration: Malignant tumor cells present derived from metastatic malignant melanoma. Comment: Immunohistochemical stains show that the tumor cells mark strongly with S-100 and HMB45. They do not mark with cytokeratin 7, cytokeratin 20, PSA, TTF-1 or RCC. These staining results support a melanocytic differentiation. Cell block and cytologic preparations Presentation material is for education purposes only. All rights reserved URMC Radiology Page 33 of 95 examined.
34 Skin, right neck, excision: Biopsy site and residual melanoma. Examined margins are free of involvement. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 34 of 95
35 Skin, right neck, excision: H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 35 of 95
36 Skin, right neck, excision: H & E stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 36 of 95
37 CASE 2: Key Facts about Metastatic Melanoma PET/CT: Scan from vertex of head through proximal thigh. Negative PET does not exclude lesions < 1 cm in size. Local Spread At or near previous excision site Metastatic Disease In-transit nodal metastases: Between primary & regional lymph nodes Regional lymph nodes Common sites: Spine, brain, lung, liver, spleen and bowel Presentation material is for education purposes only. All rights reserved URMC Radiology Page 37 of 95
38 CASE 3 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 38 of 95
39 72-year-old with history of cough. Dense opacification of the lingula with enlargement of the bilateral hila. Next test? Presentation material is for education purposes only. All rights reserved URMC Radiology Page 39 of 95
40 * Mass with associated consolidation of the left upper lobe with multiple adjacent nodules and septal thickening, as well as associated mediastinal lymphadenopathy. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 40 of 95
41 CASE 3: Differential Diagnosis Non-Small Cell Lung Carcinoma Small Cell Lung Carcinoma Lymphoma Metastases Breast Head & neck Renal Cell Melanoma Presentation material is for education purposes only. All rights reserved URMC Radiology Page 41 of 95
42 How can you minimize the risk of pneumothorax with biopsy? By going though the parasternal or transsternal region. Also beware of internal mammary vessels. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 42 of 95
43 Pathology Presentation material is for education purposes only. All rights reserved URMC Radiology Page 43 of 95
44 Case 3 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 44 of 95
45 Lung, left, CT-guided FNA: Diff-Quik stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 45 of 95
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 95
47 Lung, left, CT-guided FNA: Papanicolaou stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 47 of 95
48 Lung, left, CT-guided FNA: Papanicolaou stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 48 of 95
49 Lung, left, CT-guided fine needle aspiration: Malignant tumor cells present derived from small cell carcinoma. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 49 of 95
50 Lung, left anterior mediastinal mass, biopsy: Small cell carcinoma with extensive necrosis. Comment: Immunohistochemical stains are positive for CD56 and synaptophysin and are negative for CK 7, CK 20, TTF-1 and chromogranin supporting the diagnosis of small cell carcinoma. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 50 of 95
51 Lung, left anterior mediastinal mass, biopsy: H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 51 of 95
52 Lung, left anterior mediastinal mass, biopsy: H & E stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 52 of 95
53 Lung, left anterior mediastinal mass, biopsy: CD 56 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 53 of 95
54 Lung, left anterior mediastinal mass, biopsy: Synaptophysin Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 54 of 95
55 Lung, left anterior mediastinal mass, biopsy: TTF-1 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 55 of 95
56 CASE 3: Key Facts about Small Cell Carcinoma Large mediastinal mass Arises in proximal airway Extends to at least one hilum in 85% Endobronchial obstruction Mass envelops pulmonary arteries, aorta, great vessels Compresses/invades SVC in 10-15% Presents as solitary pulmonary nodule in 5% Presentation material is for education purposes only. All rights reserved URMC Radiology Page 56 of 95
57 CASE 4 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 57 of 95
58 * 71-year-old female with right neck and occipital pain. CT MR demonstrates shows a T1 isointense osteolytic lesion of right occipital condyle. with extension to adjacent portions of right occipital bone. Differential? Presentation material is for education purposes only. All rights reserved URMC Radiology Page 58 of 95
59 CASE 4: Differential Diagnosis Metastasis Plasmacytoma Lymphoma Chondrosarcoma Jugular Mass Neurogenic tumor, paraganglioma Presentation material is for education purposes only. All rights reserved URMC Radiology Page 59 of 95
60 What differential diagnosis is more likely now? Presentation material is for education purposes only. All rights reserved URMC Radiology Page 60 of 95
61 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 61 of 95
62 Pathology Presentation material is for education purposes only. All rights reserved URMC Radiology Page 62 of 95
63 Case 4 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 63 of 95
64 Bone, skull base, CT-guided FNA: Diff-Quik stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 64 of 95
65 Bone, skull base, CT-guided FNA: Diff-Quik stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 65 of 95
66 Bone, skull base, CT-guided FNA: Papanicolaou stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 66 of 95
67 Bone, skull base, CT-guided FNA: Papanicolaou stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 67 of 95
68 Cell block: 40x Bone, skull base, cell block: Hematoxylin and eosin stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 68 of 95
69 Bone, skull base, CT-guided fine needle aspiration: Malignant tumor cells present derived from adenocarcinoma consistent with pulmonary primary. Comment: Immunohistochemical stains are strongly positive for cytokeratin and TTF-1. There is focal marking with CD138. They do not mark with LCA. The staining results support an adenocarcinoma of pulmonary origin. Cell block and cytologic preparations Presentation material is for education purposes only. All rights reserved URMC Radiology Page 69 of 95
70 Bone, skull base, cell block: TTF-1 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 70 of 95
71 Bone, skull base, cell block: Cytokeratin Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 71 of 95
72 Bone, skull base, cell block: CD 138 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 72 of 95
73 Bone, skull base, cell block: LCA Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 73 of 95
74 CASE 4: Key Facts about Metastatic Adenocarcinoma, Lung Primary Metastases usually to regional lymph nodes, local metastases, adjacent organs PET/CT demonstrates these bone metastases much better than other imaging Presentation material is for education purposes only. All rights reserved URMC Radiology Page 74 of 95
75 CASE 5 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 75 of 95
76 Differential? 54-year old woman with a history of lung cancer status post right lower lobectomy and mediastinal lymphadenectomy on followed by chemotherapy and radiation therapy. Does this narrow your Presentation material is for education purposes only. All rights reserved URMC Radiology Page 76 of 95 differential?
77 CASE 5: Differential Diagnosis Metastases Infection Septic emboli Granulomatous Disease Primary Bronchogenic Carcinoma with metastases Presentation material is for education purposes only. All rights reserved URMC Radiology Page 77 of 95
78 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 78 of 95
79 Pathology Presentation material is for education purposes only. All rights reserved URMC Radiology Page 79 of 95
80 Case 5 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 80 of 95
81 Lung, left, CT-guided FNA: Diff-Quik stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 81 of 95
82 Bone, iliac wing, CT-guided FNA: Papanicolaou stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 82 of 95
83 Lung, left, CT-guided FNA: Papanicolaou stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 83 of 95
84 Lung, left, CT-guided FNA: Cell block, H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 84 of 95 Cell block: 40x
85 Lung, left, Cell block: TTF-1 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 85 of 95
86 Lung, left, Cell block: CK 7 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 86 of 95
87 Lung, left, CT-guided fine needle aspiration: Malignant tumor cells present derived from poorly differentiated adenocarcinoma. Immunohistochemical stains are positive for TTF-1 and cytokeratin 7 and negative for p63. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 87 of 95
88 Lung, right lower lobe, lobectomy and lymph node biopsies: Pleomorphic carcinoma with poorly differentiated adenocarcinoma and giant cell carcinoma components. Immunostains are positive for CK7 and TTF-1. Focal staining is present in CD56, synaptophysin and p63. Mucin stain is positive. Chromogranin and CK5/6 are negative. Tumor size: 5.6 x 5.4 x 3.6 cm Margins: Invasive carcinoma is focally present at the bronchial resection margin. Lymph nodes, level 7, biopsy: Metastatic adenocarcinoma present in 1/12 lymph nodes. All other level lymph nodes are negative. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 88 of 95
89 Lung, right lower lobe, lobectomy: H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 89 of 95
90 Lung, right lower lobe, lobectomy: H & E stain, 40x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 90 of 95
91 Lung, right lower lobe, lobectomy: Cytokeratin 7 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 91 of 95
92 Lung, right lower lobe, lobectomy: TTF-1 Immunostain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 92 of 95
93 Lymph node, level 7, biopsy: H & E stain, 20x Presentation material is for education purposes only. All rights reserved URMC Radiology Page 93 of 95
94 CASES CASE 1: MRN ; Poorly differentiated non-small cell carcinoma. CASE 2: MRN ; Metastatic melanoma. CASE 3: MRN ; Small cell carcinoma. CASE 4: MRN ; Adenocarcinoma compatible with lung primary. CASE 5: MRN ; Poorly differentiated adenocarcinoma. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 94 of 95
95 End Presentation material is for education purposes only. All rights reserved URMC Radiology Page 95 of 95
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