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**yaah** · 03-13-2005, 05:09 PM

Always fun to post pics!

First one: Classic lesion, don't see it much because it is often easily diagnosed on radiology. Buzzword: "Popcorn calcification." This was a solitary lung lesion in someone with a history of renal cell carcinoma. Answer is below.

Answer: Pulmonary hamartoma! It's classic - it has the cartilage, the fat, and the bronchial epithelium lining the thin spaces.

**yaah** · 03-13-2005, 05:13 PM

#2: Multiple lung lesions in a patient with a "Sinus cancer"

This one was around the bronchus and looked grossly like it could be a primary cancer of the lung (autopsy case).

Higher power:

This is an interesting tumor - easily recognized because it's pretty distinctive (although some others can mimic it). Oddly, it doesn't metastasize to the lungs very frequently. Adenoid Cystic Carcinoma. I just think it's neat how it's invading the bronchus like that.

**yaah** · 06-17-2005, 01:01 PM

Lung always provides interesting path

Anyone know what this is?

And this is always a pretty tumor

**yaah** · 06-17-2005, 01:06 PM

Large liver mass in a 1 year old:

Low power:

Higher power:

Answer (highlight the area to the right to see the answer): Mesenchymal Hamartoma

**yaah** · 06-17-2005, 01:12 PM

This is cool too:

Arterial dissection:

And its effects on the kidney

**yaah** · 06-18-2005, 06:37 AM

It was actually a cool aortic dissection case because the dissection went from the aorta proximally and caused tamponade and extended into the lungs, and distally all the way down to the iliacs, and had occluded the splenic, SMA, and one of the renals.

**yaah** · 06-18-2005, 06:42 AM

It's actually embolization particles from an interventional radiology procedure. It is from a lung that was hemorrhaging, and was embolized in IR. Didn't work, so they did a lobectomy.

2nd one is a bronchoalveolar CA.

DarksideAllstar · 06-18-2005, 08:35 AM

Quote:

Originally Posted by yaah

It was actually a cool aortic dissection case because the dissection went from the aorta proximally and caused tamponade and extended into the lungs, and distally all the way down to the iliacs, and had occluded the splenic, SMA, and one of the renals.

Did the guy live?

Edit: Hamartomas are pretty sweet.

DarksideAllstar · 06-18-2005, 08:40 AM

Parts of that slide from the lobectomy look 3-D.

**yaah** · 06-18-2005, 08:46 AM

Yes - during the autopsy he sat bolt upright and said "I'm not dead yet!" but a few seconds with the Stryker saw and the diener had him under control.

**yaah** · 06-19-2005, 07:44 AM

Old images that I posted of the gouty tophus disappeared because they were on a bad image hosting site...here they are again

Polarized gout - monkeying with the polarizer a bit:

More normal polarized appearance:

Other versions are on my other computer, will post another day.

Brian Pavlovitz · 06-19-2005, 05:47 PM

Beautiful pictures, yaah! Thanks for posting them!

...and nice job with the RISE--I must say I'm not surprised.

buddha belly · 06-19-2005, 06:08 PM

Thanks for posting these!

rpkall · 06-19-2005, 06:11 PM

Beautiful!

I can't wait to get old.

**yaah** · 06-21-2005, 06:05 AM

Gray scale:

Odd blueish one:

Normal histo of the same lesion:

deschutes · 06-23-2005, 01:01 PM

Quote:

Originally Posted by yaah

Answer (highlight the area to the right to see the answer): Mesenchymal Hamartoma

I got half the answer.

That is also my med school experience in five words.

**yaah** · 06-23-2005, 01:34 PM

Well, similar to my med school experience I guess. One problem I had was that I would often think of the right answer, yet I wouldn't say anything. Then when the attending said the answer I would curse to myself. It's odd, because I am somewhat talkative, and would offer answers on other occasions. I just noticed that often when I had a first thought in a random situation I held my tongue.

**yaah** · 06-26-2005, 06:48 PM

Pancreatic cancer with perineural invasion.

deschutes · 07-06-2005, 05:25 PM

I was looking till my eyes were sore for these today - I didn't find any.

a morula of Ehrlichia

Highlight to the right of the image for the answer.

**yaah** · 08-20-2005, 08:45 AM

Low grade papillary urothelial. Kinda cool.

**yaah** · 08-20-2005, 08:48 AM

2 Renal Tumors:

1)

2)

TigerPath05 · 08-20-2005, 12:58 PM

yaah - thanks for the cases. I think it would be great if people would put up cool & interesting cases!

**yaah** · 08-21-2005, 08:12 AM

I agree!

**yaah** · 08-21-2005, 08:13 AM

Mrbojangles · 08-22-2005, 06:31 PM

Quote:

Originally Posted by yaah

2 Renal Tumors:

1)

Isn't that a papillary renal cell carcinoma? I only know because we had one for surg path unknowns. There's supposed to be three patterns: pure papillary, trabecular, and solid. And with the pure papillary you can see foamy histiocytes taking up the fibrovascular core. Though it kind of looks trabecular too.

**yaah** · 08-22-2005, 06:42 PM

A lot of times you see mixed features. It is a papillary RCC (type I). The foamy histiocytes are pretty classic for it - the cholesterol clefts are too, although less common.

Appendiceal carcinoid invading the cecum

SLUsagar · 08-23-2005, 09:56 AM

Quote:

Originally Posted by yaah

and what's the site of this? also renal? what is it?

hey everybody...this thread started by yaah is truly sweet. Let's keep it up, and try'n put the SITE, with the answer in WHITE FONT below [ingenious idea yaah!!! you are a giant pimp].

**yaah** · 08-23-2005, 02:19 PM

Yes - the other renal cell is a clear cell - it has some cyst formation. Furman grade 2/4, although on this view you could probably argue 1/4.

The other is CMV gastritis. See the CMV cells?

**yaah** · 08-23-2005, 07:44 PM

That was curretted but not seen? Strange. One of those cases where they neglect to mention something in the clinical history of the requisition.

Oh, by the way, the patient has a history of previously resected cancer, and exam revealed a large mass.

**yaah** · 08-24-2005, 05:35 AM

Having not seen much vag path yet, I am at a bit of a loss to explain those slides. Not sure what gives you such a dense inflammatory infiltrate of so many cell types there. Syphillis?

That's also a pretty big biopsy.

Mrbojangles · 08-27-2005, 07:39 AM

Quote:

Originally Posted by AndyMilonakis

beta-HCG was over 200,000 on this puppy.

So that's what moles look like. I screen through those POCs like they're nothing.

**yaah** · 08-27-2005, 10:25 AM

Appendiceal carcinoid, with met.

**yaah** · 08-29-2005, 04:07 PM

Same tumor came up into the cecum

deschutes · 09-20-2005, 12:52 PM

Quote:

Originally Posted by AndyMilonakis

stfu1.jpg
stfu2.jpg

Um, need higher power.

stfu1 & 2??

deschutes · 09-20-2005, 08:55 PM

So many smileys. It's the beer talking

Quote:

Originally Posted by AndyMilonakis

Yes, "stfu" was on my mind when I took those pictures. Another resident and I were talking about how some people don't know when to STFU.

I agree. I've recently come to the conclusion that this so-called being "easy to work with" is sometimes simply a matter of knowing when to shut up.

Quote:

Originally Posted by AndyMilonakis

When I take these pics, I save the file as the medical record number. But of course, I change the names to random names such as to not suggest the diagnosis when I post the pics here

Your patient's MRN is suggestive of the diagnosis?

Quote:

Originally Posted by AndyMilonakis

The stfu slides were pic shots of dedifferentiated liposarcoma.

I remember now. Those things - I mean, "entities", can get rather large. Which of course you so kindly pointed out in the history

What is the significance of the TPN?

Quote:

Originally Posted by AndyMilonakis

I point to your skull and think, "low power"

I know.

I console myself with the thought that I don't run on beer.

beary · 09-20-2005, 09:07 PM

Quote:

Originally Posted by AndyMilonakis

You can see bizarre mitotic figures better under high power. But I can see them under low power too

low power fields = high power minds!

**yaah** · 09-21-2005, 07:30 AM

Quote:

Originally Posted by AndyMilonakis

You have to know these kind of things when you're a king, you know. (quote?)

Q: And how do you know that he's a king?

A: He hasn't got **** all over him.

Probably posted this before - this in comparison is a more well differentiated liposarcoma.

quant · 09-22-2005, 09:32 PM

Quote:

Originally Posted by AndyMilonakis

spell out MPM and I might give you credit

muh patchy mungs?

malignant pleural mesothelioma?

deschutes · 09-22-2005, 10:40 PM

Quote:

Originally Posted by AndyMilonakis

Hint: Hung-Man never complained of palpitations or headaches.

BTW, this mass did NOT stain positive for S100, chromogranin, or synaptophysin. OK, now your differential is now reduced to 3 things instead of 4

1) Adrenocortical carcinoma of some sort
2) Ovarian sex cord stromal tumour
3) ...dunno... lack of midiclorians?

Andy go home!

quant · 09-22-2005, 10:58 PM

Quote:

Originally Posted by AndyMilonakis

You got it. The force is strong in you. You have a high metaclorian index (Star Wars started to suck when they introduced this concept, IMHO).

Can you guess what Hung-Man has?

Hint: Hung-Man never complained of palpitations or headaches.

BTW, this mass did NOT stain positive for S100, chromogranin, or synaptophysin. OK, now your differential is now reduced to 3 things instead of 4

Some kind of CAH?

But the age of onset excludes it. No palpitations or headaches, pheochromocytoma is out.

No stain of chromogranin?....neuroendocrinal cells are out, unless this is some wicked variant.

Dunno, id still say some kind of CAH...

mcfaddens · 09-23-2005, 04:28 PM

Acc?

deschutes · 09-24-2005, 09:48 PM

Methinks thou doth protesteth too much

Quote:

Originally Posted by AndyMilonakis

OK, now your differential is now reduced to 3 things instead of 4

This is the reason I had 3 items on my list, with "adrenocortical carcinoma of some sort" at the top.

What are the other 2 differentials (or three, if you will)?

deschutes · 09-24-2005, 10:06 PM

Quote:

Originally Posted by AndyMilonakis

Methinks you need to quit yo bitchin'!

But you take it so well...

Quote:

Originally Posted by AndyMilonakis

When I think of adrenal neoplasms, I think of 4 main things:
1. Adrenal adenoma (I guess hyperplasia too...but that's not exciting)
2. Adrenal cortical carcinoma
3. Pheochromocytoma
4. Metastasis

So what does...

Quote:

this mass did NOT stain positive for S100, chromogranin, or synaptophysin.

...rule out?

synaptophysin stains neuroblastoma, that's all I know.

quant · 09-24-2005, 11:25 PM

Quote:

Originally Posted by AndyMilonakis

rules out pheo.

whoa slow down guys....
at this rate i won't have anything left to learn in the residency!!!!

deschutes · 09-25-2005, 07:56 PM

Quote:

Originally Posted by quant

at this rate i won't have anything left to learn in the residency!!!!

No such thing!!

On the other hand, I still can't convince myself that I lost anything by not doing a PSF. I mean, 20 years out no one is going to care if you did a PSF or not.

**yaah** · 09-26-2005, 07:44 AM

This happens to me every day:

Me: What's that?
Attending: What's what?
Me: The area I dotted
Attending:I have no idea, but it isn't significant.

deschutes · 09-26-2005, 09:22 AM

Quote:

Originally Posted by yaah

This happens to me every day:

Me: What's that?
Attending: What's what?
Me: The area I dotted
Attending:I have no idea, but it isn't significant.

Yeah. I've practically limited my painstaking circling to elusive blasts and Auer-rodded blasts.

~
My bone marrow biopsy patient this morning kept farting. I think I smelt beans and onions...

**yaah** · 10-07-2005, 07:41 PM

Quote:

Originally Posted by AndyMilonakis

I dunno - papillary RCC?

I have to take some pictures of the vag specimens I saw this week - some crazy shi in there.

deschutes · 10-08-2005, 08:03 PM

Pericarditis for the first. I thought of adding on myocarditis, but I don't understand why the myocardium has got fat in it.

The second, I'm going to go for broke and say it's metastatic i.e. non-lymphoid/hematopoietic. I see two cell populations (large clear cells with small round dark nuclei, and smaller basophilic cells with more open chromatin).

Otherwise clueless

deschutes · 10-08-2005, 10:04 PM

Quote:

Originally Posted by AndyMilonakis

It happened to be small cell carcinoma. And some of the morphological features are consistent with the diagnosis: single cell necrosis, molding, nuclear pleiomorphism, and mitoses.

I'm staring at the high-power. Are ANY of those features (apart from perhaps nuclear pleomorphism) in that field

Quote:

Originally Posted by AndyMilonakis

The clinical history was a distractor...on purpose.

"Distractor"? I thought it only helped! Positional chest pain

03-13-2005, 05:09 PM	#1
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Lung lesions SDN Members don't see this ad. Always fun to post pics! First one: Classic lesion, don't see it much because it is often easily diagnosed on radiology. Buzzword: "Popcorn calcification." This was a solitary lung lesion in someone with a history of renal cell carcinoma. Answer is below. Answer: Pulmonary hamartoma! It's classic - it has the cartilage, the fat, and the bronchial epithelium lining the thin spaces. __________________ We live in an amazing, amazing world, and it's wasted on the crappiest generation of spoiled idiots - Louis CK

06-17-2005, 01:06 PM	#4
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Interesting (to me, anyway) case Large liver mass in a 1 year old: Low power: Higher power: Answer (highlight the area to the right to see the answer): Mesenchymal Hamartoma

06-19-2005, 07:44 AM	#11
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Gout images Old images that I posted of the gouty tophus disappeared because they were on a bad image hosting site...here they are again Polarized gout - monkeying with the polarizer a bit: More normal polarized appearance: Other versions are on my other computer, will post another day.

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03-13-2005, 05:13 PM	#2
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	#2: Multiple lung lesions in a patient with a "Sinus cancer" This one was around the bronchus and looked grossly like it could be a primary cancer of the lung (autopsy case). Higher power: This is an interesting tumor - easily recognized because it's pretty distinctive (although some others can mimic it). Oddly, it doesn't metastasize to the lungs very frequently. Adenoid Cystic Carcinoma. I just think it's neat how it's invading the bronchus like that.

06-17-2005, 01:01 PM	#3
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Lung always provides interesting path Anyone know what this is? And this is always a pretty tumor

06-17-2005, 01:12 PM	#5
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	This is cool too: Arterial dissection: And its effects on the kidney

06-18-2005, 06:37 AM	#6
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	It was actually a cool aortic dissection case because the dissection went from the aorta proximally and caused tamponade and extended into the lungs, and distally all the way down to the iliacs, and had occluded the splenic, SMA, and one of the renals.

06-18-2005, 06:42 AM	#7
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	It's actually embolization particles from an interventional radiology procedure. It is from a lung that was hemorrhaging, and was embolized in IR. Didn't work, so they did a lobectomy. 2nd one is a bronchoalveolar CA.

06-18-2005, 08:40 AM	#9
DarksideAllstar you can pay me in bud Status: Resident Join Date: Dec 2001 Location: West of the Haight Posts: 2,149	Parts of that slide from the lobectomy look 3-D.

06-18-2005, 08:46 AM	#10
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Yes - during the autopsy he sat bolt upright and said "I'm not dead yet!" but a few seconds with the Stryker saw and the diener had him under control.

06-19-2005, 05:47 PM	#12
Brian Pavlovitz give me that marrow! Status: Resident Join Date: May 2003 Posts: 596	Beautiful pictures, yaah! Thanks for posting them! ...and nice job with the RISE--I must say I'm not surprised.

06-19-2005, 06:08 PM	#13
buddha belly Junior Member Join Date: Jun 2005 Posts: 4	Thanks for posting these!

06-19-2005, 06:11 PM	#14
rpkall Darwin Award Winner Join Date: Sep 2004 Posts: 516	Beautiful! I can't wait to get old.

06-21-2005, 06:05 AM	#15
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Gray scale: Odd blueish one: Normal histo of the same lesion:

06-23-2005, 01:34 PM	#17
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Well, similar to my med school experience I guess. One problem I had was that I would often think of the right answer, yet I wouldn't say anything. Then when the attending said the answer I would curse to myself. It's odd, because I am somewhat talkative, and would offer answers on other occasions. I just noticed that often when I had a first thought in a random situation I held my tongue.

06-26-2005, 06:48 PM	#18
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Pancreatic cancer with perineural invasion.

07-06-2005, 05:25 PM	#19
deschutes flying south Status: Fellow Join Date: Jul 2004 Location: Nomming Posts: 4,695	I was looking till my eyes were sore for these today - I didn't find any. a morula of Ehrlichia Highlight to the right of the image for the answer.

08-20-2005, 08:45 AM	#20
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Low grade papillary urothelial. Kinda cool.

08-20-2005, 08:48 AM	#21
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	2 Renal Tumors: 1) 2)

08-20-2005, 12:58 PM	#22
TigerPath05 Member Join Date: Aug 2004 Posts: 40	yaah - thanks for the cases. I think it would be great if people would put up cool & interesting cases!

08-21-2005, 08:12 AM	#23
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	I agree!

08-21-2005, 08:13 AM	#24
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506

08-22-2005, 06:42 PM	#26
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	A lot of times you see mixed features. It is a papillary RCC (type I). The foamy histiocytes are pretty classic for it - the cholesterol clefts are too, although less common. Appendiceal carcinoid invading the cecum

08-23-2005, 02:19 PM	#28
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Yes - the other renal cell is a clear cell - it has some cyst formation. Furman grade 2/4, although on this view you could probably argue 1/4. The other is CMV gastritis. See the CMV cells?

08-23-2005, 07:44 PM	#29
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	That was curretted but not seen? Strange. One of those cases where they neglect to mention something in the clinical history of the requisition. Oh, by the way, the patient has a history of previously resected cancer, and exam revealed a large mass.

08-24-2005, 05:35 AM	#30
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Having not seen much vag path yet, I am at a bit of a loss to explain those slides. Not sure what gives you such a dense inflammatory infiltrate of so many cell types there. Syphillis? That's also a pretty big biopsy.

08-27-2005, 10:25 AM	#32
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Appendiceal carcinoid, with met.

08-29-2005, 04:07 PM	#33
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	Same tumor came up into the cecum

09-23-2005, 04:28 PM	#41
mcfaddens Member Status: Attending Join Date: Aug 2005 Posts: 298	Acc?

09-26-2005, 07:44 AM	#46
yaah Boring Status: Attending Join Date: Aug 2003 Location: Fixing in 10% neutral buffered formalin Posts: 23,506	This happens to me every day: Me: What's that? Attending: What's what? Me: The area I dotted Attending:I have no idea, but it isn't significant.

10-08-2005, 08:03 PM	#49
deschutes flying south Status: Fellow Join Date: Jul 2004 Location: Nomming Posts: 4,695	Pericarditis for the first. I thought of adding on myocarditis, but I don't understand why the myocardium has got fat in it. The second, I'm going to go for broke and say it's metastatic i.e. non-lymphoid/hematopoietic. I see two cell populations (large clear cells with small round dark nuclei, and smaller basophilic cells with more open chromatin). Otherwise clueless