Presentation material is for education purposes only. All rights reserved URMC Radiology Page 1 of 98

Lung, RUL, CT-guided fine needle aspiration: Malignant tumor cells present derived from adenocarcinoma, favor colonic primary. Cell block and cytologic preparations examined. The tumor cells are positive for CDX-2 and focal positive for CK 20, negative for CK 7 and TTF-1. The results support the diagnosis of metastatic adenocarcinoma, favor colonic primary. Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 19 of 98

Lung, right upper lobe, wedge resection: Adenocarcinoma, moderately differentiated, morphologically consistent with a metastatic carcinoma of known history of rectal carcinoma. Lymph node, level 4 and level 10, biopsy: Chronic lymphocytic leukemia. Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 22 of 98

Rectum, low anterior resection: Adenocarcinoma, status post radiation therapy. K-RAS Gene Rearrangement: K-RAS Gene: Normal, no mutations in codon 12 and 13 were seen. Lymph node, pericolic: Metastatic adenocarcinoma identified in two of fifty one lymph nodes (2/51). Effacement of multiple lymph nodes by monomorphic lymphoid population consistent with previous known diagnosis of chronic lymphocytic leukemia. Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 25 of 98

Metastatic Adenocarcinoma Colonic Primary! Metastatic carcinoma to the lung more common than primary lung CA! Most common metastatic neoplasms are adenocarcinomas from breast, kidney and colon! Cytomorphology of columnar cells and elongated nuclei forming a palisade-like arrangement or clusters of signet ring- type cells! Immunohistochemical stains:! CDX-2, CK 20 positive! CK 7 negative! Histochemical mucin stain + Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 26 of 98

Lung, right upper lobe, 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. 2011 URMC Radiology Page 37 of 98

Adenocarcinoma of Lung! Adenocarcinoma: most common lung carcinoma in females and non-smokers! Positive immunostaining for CK-7, TTF-1, Napsin A, and negative for CK-20! Positive intracellular histochemical staining for mucin! Broad classification is non-small cell carcinoma (80%) versus small cell carcinoma (20%) Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 41 of 98

Rib, right posterior, CT-guided fine needle aspiration: Malignant tumor cells with focal spindle cells present derived from squamous cell carcinoma. Cell block and cytologic preparations examined. Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 52 of 98

Lung, right upper lobe, lobectomy: Pleomorphic carcinoma with extensive necrosis. The tumor consists of typical areas of squamous cell carcinoma and adenocarcinoma along with prominent spindle cell areas, consistent with a diagnosis of pleomorphic carcinoma. No metastatic carcinoma identified - 0/33 lymph nodes. Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 55 of 98

Pleomorphic Carcinoma of Lung! Rare, <1% of all lung carcinomas! Male predominance! Smokers! Subtype of sarcomatoid CA of lung! Dual malignant epithelial cell component and sarcomatoid spindle cell elements! Prognosis is poor! Early relapse of disease common Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 56 of 98

Pleural based mass, 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. 2011 URMC Radiology Page 82 of 98

Pleura, base mass, biopsy: Adenocarcinoma, most consistent with origin from lung. Comment: Immunohistochemical stain for Napsin A is strongly +.. TTF-1 and CK 7 are positive. CK 20, ER and PR, Her2, BRST2, mammoglobin and CDX-2 are negative. The staining pattern, combined with the morphology and in comparison with the patientõs s prior breast carcinoma, is most consistent with an origin from lung. Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 86 of 98

Adenocarcinoma of Lung! More common in women then men.! Tend to be peripheral in location.! Metastatic carcinoma to the lung must be ruled out.! Immunohistochemical stains TTF-1 and Napsin A, Cytokeratin 7 + Cytokeratin 20 -! Clinical history Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 87 of 98

Mediastinum, anterior, CT-guided fine needle aspiration: Atypical lymphocytes present. Please see separate flow cytometry and concurrent core biopsy report. Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 92 of 98

Soft tissue, anterior mediastinum, core needle biopsy: Thymoma. This diagnosis was rendered in conjunction with the flow cytometry specimen. Sections show core needle biopsies of soft tissue with diffuse sheets of small round blue cells with scant cytoplasm that are + for TdT, CD3, CD4 and CD8. Pancytokeratin stain is strongly +. Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 95 of 98

Soft tissue, anterior mediastinum, fine needle aspiration (flow cytometry): Flow cytometry findings most consistent with thymoma. Cytospin shows numerous small lymphocytes as well as larger forms with high N/C ratios and immature chromatin. No monoclonal B-cell population is detected. Events in the small lymphocyte gate co-express CD4 and CD9, consistent with thymic origin, with maturational loss of CD4 and CD8 in two separate populations. By side scatter versus CD45, half of events are + for cytoplasmic TdT and CD3 and negative for CD34. Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 96 of 98

Thymoma! Rarely encountered neoplasm located in anterior mediastinum.! Tumor stage is most significant prognostic factor.! Occurs in all age groups peaks in 6 th decade.! No sex predilection.! 10-80% of patients have symptoms of myasthenia gravis.! Cytologically dual populations of epithelial cells and lymphocytes in various proportions.! Differential diagnosis includes lymphoepithelioma-like CA, carcinoid tumor, precursor T-lymphoblastic lymphoma, HodgkinÕs s lymphoma, thymic CA and reactive lymphoid hyperplasia.! Immunohistochemical Stains:! Epithelial cells Ð Cytokeratin +! CD8, CD3 and CD4 +! Predominance of cortical component: TdT + Presentation material is for education purposes only. All rights reserved. 2011 URMC Radiology Page 97 of 98