Jerad M. Gardner

Primary gastrointestinal clear cell sarcoma: report of 2 cases, one case associated with IgG4-related sclerosing disease, and review of literature

Clear cell sarcoma (CCS) is a distinctive soft tissue sarcoma that shows melanocytic differentiation. Primary gastrointestinal (GI) CCSs have been rarely reported, but to our knowledge, no association between GI CCSs and immunoglobulin G4 (IgG4)-related sclerosing disease has been described in the literature. We experienced 2 cases of CCS that arose in the small intestine and metastasized to the liver. Histologic features and immunophenotype were typical of CCS. One of them showed a unique peritumoral sclerosing inflammatory reaction, which was highly reminiscent of IgG4-related sclerosing inflammatory disease. Dense lymphoplasmacytic infiltration with extensive sclerosis and obliterative phlebitis was observed in the immediate vicinity of the primary and metastatic tumors, but not in the distant areas from the tumor. The average number of IgG4-positive plasma cells was more than 50 per high-power field. We report 2 cases of primary GI CCS with one case showing a unique peritumoral IgG4-related lymphoplasmacytic sclerosing inflammation.

Smart Phone Microscopic Photography: A Novel Tool for Physicians and Trainees

Modern pathologists often practice separately from their clinicians. Photographing interesting microscopic findings enables a pathologist to capture microscopic images that can be used for interdepartmental communication, presentations, rounds, tumor boards, and teaching. Unfortunately, microscopic photography is not available to all pathologists or to trainees. Traditional photomicroscopes with mounted cameras are costly, limiting their availability. Whole slide scanning is time consuming, and access to digital accounts is also expensive. Recently, cellular phone technologies have advanced to the point that smart phones have photographic capability greater than many point-and-shoot cameras. New smart phone accessories can adapt smart phones to microscope eyepieces, thus facilitating microscopic image capturing. Priced around

Soft tissue chordomas: a clinicopathologic analysis of 11 cases.

100, these accessories are affordable and appropriate in some settings but are still bulky for trainees and clinicians to carry. Similarly, pathologists would not likely bring them into the microbiology laboratory or to a colleague’s microscope, and they are unlikely to be available in developing nations. With the goal of facilitating microscopic image capturing without additional accessories, we developed a simple method for capturing microscopic images with any smart phone camera. This technique is quick, easy to learn, and can be used by anyone at any microscope. Smart phone microscopic photography entails using the third through fifth fingers of the left hand to steady the hand on the left microscope eyepiece, holding the camera between the thumb and second finger of the left hand and second through fifth fingers of the right hand, to leave the right thumb free. By looking through the smart phone screen while focusing on the light in the ocular of the right eyepiece and slowly bringing the phone closer to the microscope, the view beneath the microscope lens will eventually fill the screen (Figure). The right thumb is free to focus the camera and capture the image. The camera’s zoom function can remove vignetting (the circular frame around the image). A video tutorial is available at http://www. youtube.com/watch?v1⁄4cfd9ViHBlR4 (accessed September 10, 2013). Additional basic smart phone camera functions can be used to produce high-quality images suitable for use in presentations, posters, and publications. Successful smart phone microscopic photography is dependent on the ability to hold the camera steady and, while initially frustrating to learn, the technique can be readily mastered. Although conceptually simple, smart phone microscopic photography is an invaluable tool for pathologists, clinicians, and trainees in many fields. This technique enables pathologists who do not own conventional microscope cameras, including those in small practices or developing nations, to obtain high-quality photomicrographs for use in a variety of clinical and educational applications, thus facilitating virtual consultations and the sharing of interesting cases. Smart phone microscopic photography also encourages trainees and clinicians to interact with microscopic images, further generating interest in histopathologic diagnostics, and encouraging a rapport between pathologists and clinicians. Another application for this technique is in endoscopy or laparoscopic surgery. To our knowledge, detailed instructions for obtaining quality smart phone microscopic photographs have not been previously published. Our technique and its potential applications are of novel interest and utility to physicians across many specialties.

Cutaneous and subcutaneous pleomorphic liposarcoma: a clinicopathologic study of 29 cases with evaluation of MDM2 gene amplification in 26.

Soft tissue chordomas (STCs) have never been systematically studied because of their rarity and the difficulty in separating them from similar-appearing lesions. Using brachyury to confirm the diagnosis, we have analyzed our experience with 11 cases. Cases coded as “chordoma” or “parachordoma” were retrieved from institutional and consultation files (1989 to 2011) and were excluded from further analysis if they arose from the bone or in a patient with previous axial chordoma. Eleven of 27 cases met inclusion criteria. Patients (8 male; 3 female) ranged in age from 13 to 71 years (mean 44 y). Tumors were located on the buttock (n=2), wrist (n=2), leg (n=2), toe (n=1), thumb (n=1), ankle (n=1), shoulder (n=1), and chest wall (n=1), ranged in size from 0.5 to 10.9 cm (mean 5.3 cm), and consisted of cords and syncytia of spindled/epithelioid cells with vacuolated eosinophilic cytoplasm and a partially myxoid background. Tumors expressed brachyury (10/10), 1 or more cytokeratins (11/11), and S100 protein (10/11). Follow-up information was available for 10 patients (69 mo; range, 2 to 212 mo). Most (n=6) were alive without disease, 2 developed local recurrence and lung metastases, and 1 developed lung metastasis only. One died with unknown disease status. STCs are histologically identical to osseous ones, but differ in their greater tendency to occur in distal locations where small size and surgical resectability result in better disease control. The existence of STC implies that notochordal remnants are not a prerequisite for chordoma development.

Primary cutaneous rhabdomyosarcoma: a clinicopathologic review of 11 cases

Pleomorphic liposarcoma (PL) is an uncommon form of liposarcoma that rarely occurs in the skin and subcutis. As its behavior in this setting is incompletely characterized, we undertook a study of a series of superficial PLs, defined as those arising or based primarily in the dermis and/or subcutis without involvement of deep structures. In addition, MDM2 gene amplification, a diagnostic signature of well-differentiated/dedifferentiated liposarcoma (WDL/DL), was evaluated to address the recent observation that this gene is amplified within PL-like areas in DL. PLs were obtained from institutional and consultation files (n=29). Cases were evaluated with respect to age, sex, location (dermis, dermis and subcutis, subcutis), size, predominant pattern (pleomorphic spindled or epithelioid), extent of lipogenic differentiation, and tumor necrosis. MDM2 amplification was analyzed using FISH on formalin-fixed, paraffin-embedded material in 26 cases. Patients ranged in age from 5 to 93 years (M:F=1.4:1). Tumors were located on the extremity (n=15), trunk (n=7), and head and neck (n=7) and involved the dermis (n=4), dermis and subcutis (n=10), and subcutis (n=15). Tumor size ranged from 0.8 to 15 cm (median=2 cm). All were mitotically active high-grade sarcomas [FNCLCC grade 2 (n=23) or 3 (n=6)] with either a pleomorphic spindled (n=24) or an epithelioid pattern (n=5) with variable extent of lipogenic differentiation [<25% (n=15), 25% to 50% (n=9), >50% (n=5)]. Necrosis was present in 3 cases. MDM2 gene amplification was present in 3 of 26 cases. Follow-up information in 24 cases (range=1 to 192 mo; median=48 mo; mean=59 mo) revealed local recurrences (4/24) but no metastasis or death from disease. We conclude that cutaneous and subcutaneous PLs, despite their high grade, have a much more favorable outcome compared with their deep-seated counterparts, most likely attributed to their small size and superficial location. The low incidence of MDM2 gene amplification in our series indicates that most superficial PLs are unrelated to WDL/DL. PL likely evolves by way of more than 1 molecular pathway.

Pathology Image-Sharing on Social Media: Recommendations for Protecting Privacy While Motivating Education.

Rhabdomyosarcoma is a malignant mesenchymal tumor with skeletal muscle differentiation. Primary cutaneous rhabdomyosarcoma is rare. We report a series of 11 cases of primary cutaneous rhabdomyosarcoma.

#InSituPathologists: how the #USCAP2015 meeting went viral on Twitter and founded the social media movement for the United States and Canadian Academy of Pathology

There is a rising interest in the use of social media by pathologists. However, the use of pathology images on social media has been debated, particularly gross examination, autopsy, and dermatologic condition photographs. The immediacy of the interactions, increased interest from patients and patient groups, and fewer barriers to public discussion raise additional considerations to ensure patient privacy is protected. Yet these very features all add to the power of social media for educating other physicians and the nonmedical public about disease and for creating better understanding of the important role of pathologists in patient care. The professional and societal benefits are overwhelmingly positive, and we believe the potential for harm is minimal provided common sense and routine patient privacy principles are utilized. We lay out ethical and practical guidelines for pathologists who use social media professionally.

Microscopic Image Photography Techniques of the Past, Present, and Future.

Professional medical conferences over the past five years have seen an enormous increase in the use of Twitter in real-time, also known as “live-tweeting”. At the United States and Canadian Academy of Pathology (USCAP) 2015 annual meeting, 24 attendees (the authors) volunteered to participate in a live-tweet group, the #InSituPathologists. This group, along with other attendees, kept the world updated via Twitter about the happenings at the annual meeting. There were 6,524 #USCAP2015 tweets made by 662 individual Twitter users; these generated 5,869,323 unique impressions (potential tweet-views) over a 13-day time span encompassing the dates of the annual meeting. Herein we document the successful implementation of the first official USCAP annual meeting live-tweet group, including the pros/cons of live-tweeting and other experiences of the original #InSituPathologists group members. No prior peer-reviewed publications to our knowledge have described in depth the use of an organized group to “live-tweet” a pathology meeting. We believe our group to be the first of its kind in the field of pathology.

Epithelioid sarcoma-like (pseudomyogenic) hemangioendothelioma, clinically mimicking dermatofibroma, diagnosed by skin biopsy in a 30-year-old man.

CONTEXT The field of pathology is driven by microscopic images. Educational activities for trainees and practicing pathologists alike are conducted through exposure to images of a variety of pathologic entities in textbooks, publications, online tutorials, national and international conferences, and interdepartmental conferences. During the past century and a half, photographic technology has progressed from primitive and bulky, glass-lantern projector slides to static and/or whole slide digital-image formats that can now be transferred around the world in a matter of moments via the Internet. OBJECTIVE To provide a historic and technologic overview of the evolution of microscopic-image photographic tools and techniques. DATA SOURCES Primary historic methods of microscopic image capture were delineated through interviews conducted with senior staff members in the Emory University Department of Pathology. Searches for the historic image-capturing methods were conducted using the Google search engine. Google Scholar and PubMed databases were used to research methods of digital photography, whole slide scanning, and smart phone cameras for microscopic image capture in a pathology practice setting. CONCLUSIONS Although film-based cameras dominated for much of the time, the rise of digital cameras outside of pathology generated a shift toward digital-image capturing methods, including mounted digital cameras and whole slide digital-slide scanning. Digital image capture techniques have ushered in new applications for slide sharing and second-opinion consultations of unusual or difficult cases in pathology. With their recent surge in popularity, we suspect that smart phone cameras are poised to become a widespread, cost-effective method for pathology image acquisition.

Adenocarcinoma in Ectopic Prostatic Tissue at Dome of Bladder: A Case Report of a Patient With Urothelial Carcinoma of the Bladder and Adenocarcinoma of the Prostate

Epithelioid sarcoma‐like (pseudomyogenic) hemangioendothelioma (ESHE) represents a rare soft tissue and bone tumor that typically presents as nodule(s) in the distal extremities of young adults. The nodules traverse several tissue planes simultaneously and can involve the dermis, subcutis, skeletal muscle and bone. ESHE shares clinical and microscopic features with epithelioid sarcoma (ES), and, accordingly, is commonly misdiagnosed as ES. However, unlike ES, which has a poor prognosis, ESHE commonly follows an indolent course. Herein, we report a case of ESHE diagnosed by skin biopsy that clinically mimicked a dermatofibroma. We also provide clinical photographs of the lesions in various stages of development, representing information that has not been previously published, to our knowledge.