A 69-year-old man was evaluated at this hospital because of progressively worsening dyspnea. Results of chest imaging were consistent with fibrotic lung disease, and tests of pulmonary function revealed a restrictive ventilatory deficit with diffusion impairment. A diagnosis was made.

A 60-year-old woman was seen in a pulmonary clinic because of increasing dyspnea. Chest imaging revealed bronchiectasis and mild, diffuse bronchial-wall thickening. A diagnostic procedure was performed.

A 76-year-old man with a history of transitional-cell carcinoma of the bladder presented with persistent fever, leukopenia, and pulmonary infiltrates. Examination of a lung-biopsy specimen revealed noncaseating granulomatous inflammation. A diagnostic test was performed.

A 78-year-old man presented with hypercalcemia and renal failure. Chest imaging studies revealed bilateral lymphadenopathy, and examination of a kidney-biopsy specimen showed an infiltrate of mononuclear cells. A diagnostic procedure was performed.

Immunoglobulin G4 (IgG4)-related disease is increasingly recognized in many organs; however, none are described in detail is the trachea. In addition, the role of surgical intervention in the disease has yet to be fully defined. We describe a patient with IgG4-related airway disease presenting as a low tracheal mass, which was treated with tracheal resection and reconstruction. This novel presentation of the disease highlights the importance of including IgG4-related disease in the differential diagnosis of tracheal masses. Further, possible indications for surgical therapy are considered. As the full clinical spectrum of IgG4-related disease continues to evolve, so too must approaches to disease management.

CONTEXT:Non-small cell lung cancer (NSCLC) is a poor-prognosis malignancy for which more effective treatments are needed, with accumulating clinical experiences supporting benefits of receptor tyrosine kinase inhibitors for patients with tumors harboring an epidermal growth factor receptor (EGFR) mutation or anaplastic lymphoma kinase ( ALK ) rearrangement.OBJECTIVE:To review completed and ongoing clinical trials of EGFR tyrosine kinase inhibitors for EGFR mutation-positive NSCLC and an ALK inhibitor for those with ALK rearrangement, while also exploring practical issues surrounding the implementation of molecular testing as a routine component of the diagnostic workup of NSCLC in the United States.DATA SOURCES:Published biomedical literature, abstracts presented at recent major oncology meetings, and ClinicalTrials.gov.CONCLUSIONS:Continually evolving evidence indicates the possible efficacy of molecularly targeted agents for the treatment of advanced NSCLC, especially adenocarcinoma. To identify patients who will most likely benefit from the targeted therapy, routine determination of the corresponding genetic alterations after histologic diagnosis of NSCLC (reflex molecular testing for EGFR mutations and ALK rearrangement) should be considered.

An 89-year-old man was admitted to the hospital because of progressive dyspnea for 6 months, worsening over the past 3 days. He had a history of exposure to asbestos and had smoked cigarettes for many years. Imaging studies revealed a pleural plaque and pulmonary interstitial fibrosis with superimposed ground-glass opacities. Hypoxemia and intermittent hypotension occurred. Despite oxygen supplementation, mechanical ventilation, and pressor administration, a cardiac arrest occurred, and the patient died on the eighth hospital day. An autopsy was performed.

Objective To improve our knowledge about the clinical,radiological and pathological features of hypersensitivity pneumonitis (HP) for correct diagnosis. Methods Two cases of subacute HPs and one chronic HP were studied clinically and pathologically. Results Interstitial inflammatory infiltration,cellular bronchiolitis and poor formed granuloma were observed in both subacute HPs. Bilateral small centrolobular nodules on high resolution CT (HRCT) were found in both of cases with patchy ground opacity in one case. The case of chronic HP had highlight feature of centrolobular interstitial fibrosis with bridging extension. The epithelial granulomas were sparse in this case. There were bilateral diffuse stripes of infiltration along the bronchial vesicular bundle with focal patching accentuation on HRCT of chronic HP. Conclusions Approach to the diagnosis of HP is multidisciplinary because of diverse clinical,radiological and pathological features.

A 36-year-old man was admitted to the hospital because of chest pain, dysphagia, and pleural and mediastinal calcifications. He had had intermittent chest pain for 6 years after an athletic injury; dysphagia, dyspnea, and weight loss had developed over the past 2 years. Imaging studies showed pleural and mediastinal calcifications, with an esophageal stricture. Surgical procedures were performed to relieve esophageal stricture and obtain tissue for diagnosis, but symptoms recurred and biopsy specimens disclosed bony tissue with no malignant cells.

Context.—Whole-slide imaging technology offers promise for rapid, Internet-based telepathology consultations between institutions. Before implementation, technical issues, pathologist adaptability, and morphologic pitfalls must be well characterized. Objective.—To determine whether interpretation of whole-slide images differed from glass-slide interpretation in difficult surgical pathology cases. Design.—Diagnostically challenging pathology slides from a variety of anatomic sites from an outside laboratory were scanned into whole digital format. Digital and glass slides were independently diagnosed by 2 subspecialty pathologists. Reference, digital, and glass-slide interpretations were compared. Operator comments on technical issues were gathered. Results.—Fifty-three case pairs were analyzed. There was agreement among digital, glass, and reference diagnoses in 45 cases (85%) and between digital and glass diagnoses in 48 (91%) cases. There were 5 digital cases (9%) discordant with both reference and glass diagnoses. Further review of each of these cases indicated an incorrect digital whole-slide interpretation. Neoplastic cases showed better correlation (93%) than did cases of nonneoplastic disease (88%). Comments on discordant cases related to digital whole technology focused on issues such as fine resolution and navigating ability at high magnification. Conclusions.—Overall concordance between digital whole-slide and standard glass-slide interpretations was good at 91%. Adjustments in technology, case selection, and technology familiarization should improve performance, making digital whole-slide review feasible for broader telepathology subspecialty consultation applications.

A 63-year-old woman was admitted to the hospital because of a 3-week history of dyspnea on exertion, associated left subscapular burning pain, and a mild dry cough. She had a history of ulcerative colitis, which was most recently treated with azathioprine and infliximab. On examination, there were inspiratory wheezes and rales, without expiratory wheezes. Chest imaging showed ground-glass opacities in both lower lobes. A diagnostic procedure was performed.

We are pleased to bring to readers of the Archives reviews that are based on contributions prepared to accompany talks given at the 28th annual postgraduate course “Current Concepts in Surgical Pathology,” organized by the Department of Pathology, Massachusetts General Hospital, under the auspices of the Department of Continuing Medical Education of Harvard Medical School. Before we make a few remarks on the course itself, we will make a few brief comments on the history of these exercises, and the tradition of postgraduate education in general, which we hope will be of interest to many readers.Postgraduate pathology education dates, in large measure, back to the learned pathology societies of Europe, which in the late 19th century began to have frequent meetings, the proceedings of which were published as “Transactions” and are still an enjoyable and instructive read, stumbling as one often does on the words of the past giants. As Dr Juan Rosai discussed in a talk at the meeting of the History of Pathology Society at the last (2007) meeting of the United States and Canadian Academy of Pathology in San Diego, the tradition of slide seminars has been an arm of pathology postgraduate education for at least 50 years in the United States. The well-known Case Records of the Massachusetts General Hospital are, of course, also vehicles for education of those in their postgraduate years, as well as others.Continuing Medical Education courses in our department date back to a course on endocrine pathology that Dr Benjamin Castleman, Dr Austin L. Vickery, Jr, and Dr Robert E. Scully and others first organized circa 1960 (interestingly, 8 years before the Department of Continuing Medical Education at Harvard Medical School was founded) and ran successfully for about 15 years. It was very labor intensive due to the preparation of slide sets for study by the participants and was stopped largely for that reason, but it was soon replaced by a course on obstetric and gynecologic pathology that continues to this day. That was soon followed by the first offering of the “Current Concepts in Surgical Pathology” course covering all areas of surgical pathology, and one of the course directors (E.J.M.) has lectured at each of the 28 installments. A number of other courses of subspecialized nature ensued and have now been instituted for some years, including gastrointestinal pathology, obstetric and gynecologic pathology, urologic pathology, dermatopathology, and asbestos-related lung disease. A few of these courses have been jointly organized with our fellow Harvard Medical School faculty at the Brigham and Women's Hospital. More recently, courses in breast pathology and thoracic pathology have been given conjointly with colleagues at Memorial Sloan-Kettering Cancer Center in New York City.We currently offer the “Current Concepts” course every November, and selected proceedings are given here. Pathology courses can be aimed at several levels, ranging from highly selected areas directed at a small number of expert practitioners or investigators to more broadly based courses aimed at either investigators or practitioners at academic or nonacademic affiliated hospitals. This course has been aimed primarily at the latter, with particular emphasis on encouraging fresh approaches to recurring problems across the spectrum of anatomic pathology. The course has steadily attracted between 150 and 200 participants over the years. The field of surgical pathology is well suited for postgraduate courses since, as opposed to information that can be disseminated at courses for internal medicine or surgery in a theoretical manner, images and glass slides as depicted at pathology courses are our primary database, and a pathology course thereby is a very direct method of education. As our course has suggested since its inception, the hematoxylin-eosin slide will still be in play after the great majority of results currently dominating pathology journals will be footnotes.The conventional courses that we are all familiar with will likely be the mainstay of this type of activity for years to come. There is something about the educational value of hearing a good speaker in person that is not likely to be surpassed for the foreseeable future, associated as it is with the opportunity to ask questions informally or formally. Furthermore, for the majority who are not from the area where the course is being given, the attraction of taking a course in a pleasant location away from the demands of daily practice provides a welcome break from the routine. The aforementioned comments notwithstanding, it is clear that modern technology will enhance and to some degree alter these offerings as the years go by, and indeed that has happened already to an extent. Digital images on CD-ROM are already part of many courses or are available for an additional fee, although the extent to which these are widely used by registrants after the course remains an open question in our minds. This year, the slide seminar sessions will be available online in a format such that persons will not only be able to see the slides but hone in on selected areas of the slide at increasingly high magnification. The course itself will also be online with video and audio streaming. The range of the Internet both in terms of advertising and disseminating information must have increased the visibility of the course, as one third of our attendees now come from abroad.We have selected contributions in areas that provide frequent and recurring problems in daily practice of surgical pathology or in some instances are simply the source of new concepts or innovative approaches. We hope the reader enjoys the articles.

A 20-year-old woman with a history of severe asthma was found at home in an unresponsive state and was taken to the emergency room. Asthma had been diagnosed at 4 years of age, with multiple exacerbations thereafter that required hospitalization. The patient and her mother had not followed environmental and medication regimens. In the weeks before admission, the patient had visited many emergency rooms and clinics because of exacerbations. She was pronounced dead shortly after arrival. An autopsy was performed.

Presentation of CaseA 43-year-old man was admitted to the hospital because of fever and rapid deterioration of vision in the left eye.The patient had been well until six weeks earlier, when fevers, sweats, myalgias, and right-sided pleuritic chest pain developed. Three days later, a chest radiograph reportedly showed pneumonia in the right lower and middle lobes. A five-day course of azithromycin was prescribed. He felt better with treatment, but one day after the course of medication ended, he felt worse. Twenty-six days before admission, a repeated chest radiograph revealed a right-sided pleural effusion. He refused to undergo thoracentesis . . .

Presentation of CaseA 47-year-old man was evaluated in the pulmonary clinic because of waxing and waning pulmonary lesions several years after treatment for seminoma.The patient had been well until five years earlier, when a left testicular seminoma was diagnosed. A left radical orchiectomy was performed; there was no evidence of lymphatic or blood-vessel invasion, and the resection margins, epididymis, and spermatic cord were free of tumor. A computed tomographic (CT) study of the chest, performed after the oral administration of contrast material, disclosed slight anterior pericardial thickening, with no axillary, hilar, or mediastinal lymphadenopathy or evidence of pulmonary . . .