81 Stump the Stars 2011: Problem Cases in Hematopathology. Steven Kroft MD Russell Brynes MD LoAnn Peterson MD Eric Hsi MD Kaaren Reichard MD

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1 81 Stump the Stars 2011: Problem Cases in Hematopathology Steven Kroft MD Russell Brynes MD LoAnn Peterson MD Eric Hsi MD Kaaren Reichard MD 2011 Annual Meeting Las Vegas, NV AMERICAN SOCIETY FOR CLINICAL PATHOLOGY 33 W. Monroe, Ste Chicago, IL 60603

2 81 Stump the Stars 2011: Problem Cases in Hematopathology This engaging, interactive session will address five unusual cases in hematopathology, including case histories with pertinent morphology and quantitative data. An audience response system will be used to poll for the next steps for a final differential diagnosis, followed by discussions, references, and solutions. Develop new diagnostic algorithms. Recognize morphologic features of uncommon hematolymphoid diseases. Reevaluate your diagnostic capabilities. FACULTY: Steven Kroft MD Russell Brynes MD LoAnn Peterson MD Eric Hsi MD Kaaren Reichard MD Practicing Pathologists Hematopathology Hematopathology 2.0 CME/CMLE Credits Accreditation Statement: The American Society for Clinical Pathology (ASCP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). Credit Designation: The ASCP designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. ASCP continuing education activities are accepted by California, Florida, and many other states for relicensure of clinical laboratory personnel. ASCP designates these activities for the indicated number of Continuing Medical Laboratory Education (CMLE) credit hours. ASCP CMLE credit hours are acceptable to meet the continuing education requirements for the ASCP Board of Registry Certification Maintenance Program. All ASCP CMLE programs are conducted at intermediate to advanced levels of learning. Continuing medical education (CME) activities offered by ASCP are acceptable for the American Board of Pathology s Maintenance of Certification Program.

3 Case 1 A 56 year-old Caucasian male with a history of diabetes and stroke presented for evaluation of progressively worsening shortness of breath with associated paroxysmal nocturnal dyspnea. During the clinical investigation, a TEE revealed the presence of a presumed left atrial myxoma and severe (4+) mitral regurgitation. While in the operating room, the surgeon noted the atrial mass arose from a stalk protruding from the lateral margin of the fossa ovalis. The mass was excised. A section is provided.

4 Atrial Mass Resection in a 56 y.o man Preoperative clinical impression: atrial myxoma Hematoxylin and eosin (20x)

5 H&E 100x

6 H&E 400x

7 Case 2 The patient presented in 2004 at age one year with fatigue. WBC was 10.6 K/uL, Hb 8.3 g/dl, MCV 85 fl, platelets 127 K/uL. Images from a bone marrow aspirate and biopsy are provided. Karyotyping revealed a t(9;11)(p22;q23). Treatment resulted in a complete remission. The patient re-presented in 2010 at age 7, after being off therapy for 5 years, with a facial mass and pancytopenia. WBC 5.1 K/uL, Hb 8.6 g/dl, MCV 84 fl, platelets 110 K/uL. Flow cytometric analysis revealed cells that were CD19(+), CD22(+), CD10(+), TdT(+), CD45(dim+), and subset weak surface lambda(+).

8 Peripheral blood smear (2004)

9 Bone marrow aspirate (2004)

10 Bone marrow aspirate (2004)

11 Bone marrow aspirate (2004)

12 Bone marrow core biopsy (2004)

13 Non specific esterase cytochemical stain (2004)

14 Peripheral blood smear (2010)

15 Bone marrow aspirate (2010)

16 Bone marrow aspirate (2010)

17 Case 3 The patient is a 38-year-old man who presented with a two-month history of fever and cough. His chest films showed progression from an interstitial/nodular infiltrative pattern to cavitary lesions. A sputum sample was positive for Aspergillus species. The patient was placed on broad spectrum antibiotics and steroids and appeared to improved somewhat. Because the infiltrates persisted, biopsies of right lower, middle, and upper lobes were obtained.

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24 CD3

25 CD3

26 CD20

27 CD20

28 EBER

29 Case 4 The patient is a 63 year old man who presented with incessant bleeding following a tooth extraction. As part of a work up for the bleeding, he underwent a bone marrow biopsy and a diagnosis was made. Two months later, he moved to Chicago and presented for evaluation related to his new diagnosis. He was largely asymptomatic except for other episodes of epistaxis related to removing dry scabs from the nose.

30 Physical examination was normal there was no lymphadenopathy or other organomegaly. Past medical history included coronary artery disease (3 stents and coronary artery bypass grafting), hypertension on therapy, appendectomy, and gunshot wound to hand (8 years prior). His occupation was contract negotiator for State of Illinois (retired). Current medications include: vitamins, metroprolol, clopidogel, Sensipar, Zocor and cinacalcet. He underwent a second bone marrow biopsy for genetic studies and because 12% blasts were being reported in the blood that had not been noted in his prior differential cell counts. The CBC at the time of this biopsy (the one the stars review) is as follows: WBC 15.2 k/µl Red Cell Count 5.03 m/µl Hemoglobin 12.1 g/dl Hematocrit 38.0% Platelet count 392k/µL

31 Peripheral Blood

32 Bone Marrow Aspirate

33 Bone Marrow Core Biopsy

34 Bone Marrow Core Biopsy

35 Bone Marrow Core Biopsy