Radiology/Pathology Conference

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Stephanie Snow
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Case 1 65 year old female presents with painless jaundice and dark urine.

Case 1 Presentation material is for education purposes

10 Pancreatic Adenocarcinoma 1) Hypovascular mass with ductal dilatation. 2) Infiltrative, poor margins. 3) Vascular encasement. 4) Poor prognosis. 5) Most common pancreatic primary. 6) Seen in older males. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 10 of 132

11 Islet Cell Tumor 1) Hypervascular. 2) Vascular encasement not often seen. 3) Insulinoma most common type. 4) Seen with Zollinger- Ellison and MEN 1. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 11 of 132

12 Lymphoma 1) Usually seen with local spread of non- Hodgkin variant. 2) Associated with abdominal or pelvic adenopathy. 3) Vascular encasement less common. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 12 of 132

16 Pathology Workup of the patient included endoscopic brushings and biopsies, FNA left supraclavicular lymph node, surgical biopsy of the left supraclavicular lymph node, and ex lap mesenteric node and pancreatic mass core biopsies. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 16 of 132

Case 1 Lymph node, US-guided FNA: Presentation material is for education

Lymph node, US-guided FNA: Presentation material is for education purposes

Lymph node, US-guided FNA: Papanicolaou stain Presentation material is for

20 Lymph node, left supraclavicular, ultrasound-guided fine needle aspiration: No evidence of metastatic carcinoma. Cellular evidence of a mixed lymphoid population including tingible body macrophages suggestive of a reactive lymph node. Comment: Recommend repeat aspiration for flow cytometry or lymph node biopsy to definitively exclude lymphoma if clinically indicated. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 20 of 132

Lymph node, left supraclavicular, biopsy: H & E stain Presentation material is

Lymph node, left supraclavicular, Presentation material is for education purposes

Lymph node, left supraclavicular, Presentation material is for education

25 Lymph node, left supraclavicular, excisional biopsy: Follicular lymphoma, grade I. Comment: There is significant sclerosis in this node. Some studies suggest that sclerosis is associated with a shorter progression free survival. Flow cytometry (CD20/CD10/Kappa/Lambda/CD45): Atypical pattern with a subpopulation of CD20/10/Kappa positive cells which comprise at most 5% of total events in the specimen. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 25 of 132

Pancreas, head, ultrasound-guided fine needle aspiration: Diff-Quik stain Presentation

Pancreas, head, ultrasound-guided fine needle aspiration: Papanicolaou stain Presentation

Pancreas, US-guided FNA: Presentation material is for education purposes only.

29 Pancreas, head, endoscopic ultrasoundguided fine needle aspiration: Rare atypical cells present suspicious for, but not diagnostic, of adenocarcinoma. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 29 of 132

Soft tissue, mesenteric lymph node, biopsy: H & E stain Presentation material is

33 (B) Soft tissue, mesenteric lymph node, biopsy: Large B-cell lymphoma Comment: Sections of part B show adipose tissue that is diffusely infiltrated by large atypical lymphocytes without any nodal architecture nor lymph node capsule seen. The neoplastic cells are strongly positive for CD79a and CD20, consistent with B-cell origin, and are negative for pancytokeratin, synaptophysin, CD56, chromogranin, and p53. The proliferation fraction by Ki67 is high (>90%). (A) Soft tissue, pancreas, biopsy: Fibroadipose tissue with minute focus of small mature lymphocytes, cannot exclude low-grade lymphoma. (C) Soft tissue, lymph nodes, mesenteric, biopsy: No malignancy seen. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 33 of 132

34 Follicular Lymphoma 20% of all lymphomas M:F=1:1.7, median age 6 th decade, rare under the age of 20 Predominantly involves lymph nodes, but can be extranodal, more often in widespread disease Derived from follicle center/germinal center B-cells with both centrocytes (small) and centroblasts (large) Graded based on number of large cells per HPF (grade 1-2 low, grade 3 high) and follicular versus diffuse pattern Most patients present with widespread disease, but otherwise asymptomatic Any area of DLBCL is reported as the primary diagnosis with estimate of amount of FL and DLBCL Immunohistochemistry: B-cell markers (CD20, CD79a, etc.), BCL2, BCL6, CD10 Genetics: t(14;18) with BCL2 rearrangements (not all cases) Prognosis: Grade 1-2 indolent (72% 5 yr survival), Grade 3 more aggressive but treatable by chemo, transformation to DLBCL poor prognosis (25-35% of patients) Presentation material is for education purposes only. All rights reserved URMC Radiology Page 34 of 132

35 Solid Pancreatic Mass Quick Review 1) Adenocarcinoma: hypovascular, infiltrative, vascular encasement 2) Islet cell tumor: hypervascular, vascular encasement not often seen 3) Lymphoma: lymph nodes, vascular encasement less common Presentation material is for education purposes only. All rights reserved URMC Radiology Page 35 of 132

Case 2 80 year old male presents with hemoptysis.

37 Case 2 As part of the workup a chest radiograph and CT angiogram chest are ordered. What do you see? Presentation material is for education purposes only. All rights reserved URMC Radiology Page 37 of 132

Case 2 Presentation material is for education purposes

Benign Thyroid Nodule 1) They are common 2) Hyperplasia, colloid cyst, adenoma 3) Rim/eggshell calcs, cystic components, thin regular hypoechoic halo 4) Variable

45 Benign Thyroid Nodule 1) They are common 2) Hyperplasia, colloid cyst, adenoma 3) Rim/eggshell calcs, cystic components, thin regular hypoechoic halo 4) Variable appearance 5) Colloid cyst: hyperechoic foci with comet tail artifact Presentation material is for education purposes only. All rights reserved URMC Radiology Page 45 of 132

46 Parathyroid Adenoma 1) Normal gland not seen on routine exam due to small size. 2) Solid, hypoechoic, ovoid; posterior to thyroid gland. 3) Vascular. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 46 of 132

Thyroid Malignancy 1) Males, <20, >60, radiation, family history. 2) Varied appearance. 3) Irregular borders. 4) Lymph nodes. 5) Avascular nonspecific but points towards benign.

47 Thyroid Malignancy 1) Males, <20, >60, radiation, family history. 2) Varied appearance. 3) Irregular borders. 4) Lymph nodes. 5) Avascular nonspecific but points towards benign. 6) Papillary cancer: microcalcs in hypoechoic solid nodule. 7) SRU Consensus for FNA. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 47 of 132

2006 SRU Consensus Statement Presentation material is for education

Case 2 Thyroid, right, US-guided FNA: Diff-Quik stain Presentation material is

Thyroid, right, US-guided Presentation material is for education purposes

Thyroid, right, US-guided Presentation material is for education purposes only.

54 Thyroid, right, ultrasound-guided fine needle aspiration: Papillary thyroid carcinoma. Comment: The aspirate shows abundant follicular cells with nuclear changes consistent with papillary carcinoma. Some cell groups show microfollicles which may indicate a follicular variant of PTC. Case sent for BRAF testing. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 54 of 132

55 Thyroid, right, ultrasound-guided fine needle aspiration: Molecular Pathology Report: BRAF Mutant. Positive for the V600E mutation in the BRAF gene. This mutation is found frequently (30-60%) in papillary thyroid carcinoma, but not in other thyroid neoplasms (ref: Kimura et al. 2003, Cancer Res. Vol. 63, p. 1454). Thus, this result is consistent with a diagnosis of papillary thyroid carcinoma. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 55 of 132

Lung, LUL, endobronchial biopsy: H & E stain Presentation material is for

59 Papillary Thyroid Carcinoma 75-80% of thyroid carcinomas Most often women of reproductive age (70%) Risk factors: ionizing radiation, FAP, possibly Hashimoto s, family history 10-year survival 98%, nodal mets do not affect survival Poor prognostic signs: age>40, male, local invasion, distant mets, large size, lymphatic invasion, unfavorable histologic subtype Molecular: BRAF point mutation (associated with older age, more aggressive disease), RET/PTC rearrangements (younger age, classic morphology), RAS point mutations (follicular variant, low rate of nodal mets), RET amplification associated with radiation induced cases Presentation material is for education purposes only. All rights reserved URMC Radiology Page 59 of 132

60 Thyroid Mass Review 1)Benign nodule: regular borders, eggshell calcs, cystic comp, colloid cyst. 2)Parathyroid adenoma: hypoechoic, posterior to thyroid. 3)Malignancy: irregular borders, lymph nodes, microcalcs, size. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 60 of 132

Case 3 59 year old male with distal esophageal mass on endoscopy.

62 Case 3 Differential diagnosis for short segment esophageal stricture? Do not have original esophagram. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 62 of 132

63 Esophageal Carcinoma 1) Squamous: most common; smoking and alcohol risk factors. 2) Adeno: Barrett esophagitis. 3) Imaging: fixed narrowing, annular, shouldering. 4) Poor prognosis, 5% 5 year survival. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 63 of 132

64 Reflux Esophagitis Stricture 1)Reflux esophagitis common. 2)Smooth tapered narrowing. 3)Ulcerations are common. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 64 of 132

65 Drug-Induced Stricture 1) Quinidine, KCl, Alendronate, NSAIDs. 2) Seen in areas of extrinsic compression from adjacent structures such as aortic arch and left mainstem bronchus. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 65 of 132

Case 3 Presentation material is for education purposes

CT Guided Biopsy Presentation material is for education

71 Pathology Workup of the patient included endoscopic biopsy of the esophagus lesion and CT guided biopsy of the liver lesion. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 71 of 132

Case 3 Liver, CT-guided FNA: Diff-Quik stain Presentation material is for

Liver, CT-guided Presentation material is for education purposes only.

76 Liver, CT-guided fine needle aspiration: Malignant tumor cells present derived from metastatic poorly differentiated carcinoma (see concurrent surgical pathology case). Presentation material is for education purposes only. All rights reserved URMC Radiology Page 76 of 132

Liver, left lobe, biopsy: H & E stain Presentation material is for

79 Liver, left lobe, biopsy: Adenocarcinoma. Comment: No normal hepatic parenchyma present. The adenocarcinoma is compatible with metastasis from primary esophageal adenocarcinoma. Pending comparison with prior pathology when slides become available for review. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 79 of 132

80 Esophagus, 43 cm, biopsy (7/29/10): Adenocarcinoma, poorly differentiated, depth of invasion cannot be determined. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 80 of 132

81 Esophageal Adenocarcinoma 40-50% of esophageal carcinomas, increasing in incidence Age>50, 80% male 95% arise in the setting of Barrett esophagus 5 year survival 15-25% Usually present with advanced disease Metastases to liver, lung, pleura Treatment: resection +/- adjuvant/neoadjuvant chemoradiation Presentation material is for education purposes only. All rights reserved URMC Radiology Page 81 of 132

82 Short Segment Esophageal Stricture Quick Review 1)Reflux stricture: smooth, tapering, ulcerations 2)Drug-Induced: near areas of extrinsic compression 3)Carcinoma: squamous, adeno, often annular, shouldering, poor prognosis Presentation material is for education purposes only. All rights reserved URMC Radiology Page 82 of 132

83 Case 4 66 year old female with incidental liver lesions found on outside CT for workup of kidney stones. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 83 of 132

Case 4 Presentation material is for education purposes

Metastatic Disease 1) Liver most common place for metastasis after LN. 2) Colon, breast, stomach, lung, pancreas most common. 3) Neuroblastoma most common in children.

88 Metastatic Disease 1) Liver most common place for metastasis after LN. 2) Colon, breast, stomach, lung, pancreas most common. 3) Neuroblastoma most common in children. 4) Most enhance after contrast, but lesions become conspicuous due to normally enhancing adjacent parenchyma. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 88 of 132

89 Hepatic Cysts 1)Well circumscribed, homogenous, water attenuation. 2)No enhancement. 3)Common. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 89 of 132

90 Hepatic Abscesses 1) Seen most commonly with diverticulitis and sepsis. 2) Thick walled, hypoattenuating, septations, peripheral enhancement, gas. 3) High mortality rate untreated. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 90 of 132

Cholangiocarcinoma 1) Rare cancer of bile ducts. 2) Hypoattenuating infiltrative lesions parallelling bile ducts. 3) Biliary obstruction. 4) Delayed enhancement > 10 mins.

91 Cholangiocarcinoma 1) Rare cancer of bile ducts. 2) Hypoattenuating infiltrative lesions parallelling bile ducts. 3) Biliary obstruction. 4) Delayed enhancement > 10 mins. 5) Risk factors: PSC, flukes, choledochal anomalies, thoratrast exposure. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 91 of 132

Case 4 Liver, CT-guided FNA: Presentation material is for education purposes

Liver, CT- guided FNA: Diff-Quik stain Presentation material is for

Liver, CT-guided FNA: Papanicolaou stain Presentation material is for

98 Liver, CT-guided fine needle aspiration: Malignant tumor cells present derived from neuroendocrine carcinoma (please see concurrent surgical pathology report). Presentation material is for education purposes only. All rights reserved URMC Radiology Page 98 of 132

Liver, lesion, biopsy: H & E stain Presentation material is for

Liver, lesion, biopsy: Immunohistochemical

material is for education purposes only.

102 Liver, lesion, biopsy: Metastatic well-differentiated neuroendocrine carcinoma. Comment: IHC and special stains performed. Positive: Keratin, synaptophysin, chromogranin, and CD56 Negative: p63, Kreyberg (mucin) Presentation material is for education purposes only. All rights reserved URMC Radiology Page 102 of 132

103 Metastatic Tumors in Liver 98% of hepatic malignancies due to mets in noncirrhotic livers (in US) versus 23% in cirrhosis Adult primaries: breast, lung, colon, pancreas Peds primaries: neuroblastoma, Wilm s, rhabdomyosarcoma Survival usually less than 1 year, except neuroendocrine carcinoma (or neuroblastoma or colon CA with resection) PEN: 40% 5 year survival for unresected liver mets (75% for resected with control of primary) 90% multiple, often with necrosis, can replace entire liver Neuroendocrine tumors: Mets only way to tell benign from malignant Presentation material is for education purposes only. All rights reserved URMC Radiology Page 103 of 132

104 Hypoattenuating Liver Lesions Quick Review 1) Cysts: common, H20 attenuation, no enhancement 2) Metastasis: liver common place, more conspicuous with contrast 3) Abscesses: diverticulitis, sepsis, thick walled, peripheral enhancement, sometimes gas 4) Cholangiocarcinoma: along bile ducts, biliary obstruction, delayed enhancement Presentation material is for education purposes only. All rights reserved URMC Radiology Page 104 of 132

Case 5 68 year old male presents with severe back pain, worsening over months.

Case 5 Presentation material is for education purposes

Metastasis 1) Purely osteolytic lesions include thyroid, renal, and uterine carcinomas. Thyroid and renal lesions may produce bone expansion.

112 Metastasis 1) Purely osteolytic lesions include thyroid, renal, and uterine carcinomas. Thyroid and renal lesions may produce bone expansion. 2) Mixed lesions include lung, breast, cervix, testicular, ovarian. 3) Prostate more commonly osteosclerotic. 4) T1 low signal spine MR. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 112 of 132

113 Multiple Myeloma 1) Most common primary bone malignancy in adults. 2) Axial skeleton typical site of involvement. 3) Osteolytic. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 113 of 132

114 Lymphoma 1) Non-Hodgkins usually lytic while Hodgkins is usually sclerotic. 2)Multiple lytic lesions. 3)Soft tissue masses common. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 114 of 132

Case 5 As part of the workup an MRI spine is done. What do you see?

118 Pathology Workup of the patient included CT guided biopsy of spine lesion. PSA was found to be extremely elevated. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 118 of 132

Case 5 Spine, T8, CT-guided FNA: Diff-Quik stain Presentation material is for

Spine, T8, CT-guided FNA: Presentation material is for education purposes only.

Spine, T8, CT-guided FNA: Immunohistochemical

123 Spine, T8, CT-guided fine needle aspiration: Metastatic poorly differentiated carcinoma consistent with prostate primary. Comment: Immunohistochemical stains: Positive: pancytokeratin, PSA Negative: CK7, CK20, S100 Presentation material is for education purposes only. All rights reserved URMC Radiology Page 123 of 132

Bone, T8 vertebral body, biopsy: Presentation material is for education

Bone, T8 vertebral body, biopsy: Presentation material is for education purposes only.

128 Bone, T8 vertebral body, biopsy: Metastatic poorly differentiated carcinoma, suggestive of origin from prostate primary. Comment: Sections show an infiltrate of cohesive pleomorphic tumor cells consistent with metastatic carcinoma. IHC done: Positive: CK AE1/3, PSA, PAP Negative: CK7, CK20, TTF1 This immunophenotype is most suggestive of a prostate primary. Clinical and radiographic correlation is recommended. Presentation material is for education purposes only. All rights reserved URMC Radiology Page 128 of 132

129 Prostate Carcinoma 2nd leading cause of cancer-related death among American men (after lung) Most commonly diagnosed cancer in American men 1:10 men will develop prostate carcinoma in United States (only 3% DOD) More common in African-American men Often have elevated PSA (prostate cancer cells secrete 10x PSA as normal cells) Bony mets are usually osteoblastic More often lumbar spine, sacrum, or pelvis Presentation material is for education purposes only. All rights reserved URMC Radiology Page 129 of 132

Multiple Lytic Foci Review 1) Metastasis: remember ThRU, thyroid, renal, uterine for pure lytic 2) Multiple myeloma: most common primary bone malig in adults 3) Lymphoma:

130 Multiple Lytic Foci Review 1) Metastasis: remember ThRU, thyroid, renal, uterine for pure lytic 2) Multiple myeloma: most common primary bone malig in adults 3) Lymphoma: non-hodgkins lytic, Hodgkins sclerotic, soft tissue masses common Presentation material is for education purposes only. All rights reserved URMC Radiology Page 130 of 132

131 Works Cited Images: STAT dx, URMC, Frates, Mary C., et al. Management of Thyroid Nodules Detected at US. Radiology 2005;237: O Brien Sr., William T., et al. Top 3 Differentials in Radiology. New York: Thieme Medical Publishers, Inc., WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, IARC Press, 4 th Edition, Presentation material is for education purposes only. All rights reserved URMC Radiology Page 131 of 132

The End Presentation material is for education purposes

Radiology Pathology Conference

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