Slide Seminar Spanish Society of Pathology
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1 Slide Seminar Spanish Society of Pathology John R. Goldblum, M.D. Chairman, Department of Anatomic Pathology Cleveland Clinic Professor of Pathology Cleveland Clinic Lerner College of Medicine
2 1921 Original Clinic Building (still in use today) Born in War. Tested in Peace Lou Ruvo Center for Brain Health - Nevada 1921
3 Case History 12-year-old male with a 3.5-cm soft tissue mass of the left forearm
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8 Ancillary Studies AE1/AE3 - Desmin + (focal) CD99 + (focal) EMA - S100 protein - SMA - EWS FISH + EWSR1
9 Case Diagnosis Angiomatoid (malignant) Fibrous Histiocytoma
10 Fibrohistiocytic Tumors best used as a descriptive term with no histogenetic implications, to encompass a heterogeneous group of tumors that share histologic similarities. Calonje E, Fletcher CDM. Adv Anat Pathol, 1994
11 Fibrohistiocytic Tumors Benign Benign fibrous histiocytoma Juvenile xanthogranuloma Reticulohistiocytoma Xanthoma
12 Fibrohistiocytic Tumors Malignant Storiform-pleomorphic Myxoid Giant cell Inflammatory Undifferentiated pleomorphic sarcoma
13 Fibrohistiocytic Tumors Low Malignant Potential Atypical fibroxanthoma DFSP / Bednar tumor Giant cell fibroblastoma Plexiform fibrohistiocytic tumor Angiomatoid fibrous histiocytoma Giant cell tumor of soft tissue
14 Angiomatoid Fibrous Histiocytoma Majority of patients < 20 years Majority located on extremities Slow-growing subcutaneous mass Fever, weight loss, anemia
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21 AFH: Immunophenotype Desmin 50% EMA 50% CD99 45% CD68 30% MSA/SMA <15% S100 protein - AE1/AE3 -
22 AFH: Genetics Waters et al. Cancer Genet Cytogenet 2000
23 AFH: Genetics Hallor KH et al. Genes Chromosome Cancer 2005
24 AFH: Genetics EWSR1 rearrangement Oliveira 12/24 (50%) EWSR1-CREB1 7 EWSR1-ATF1 3 EWSR1-alternate 2 FUS-ATF1 1 Tanas 13/17 (86%)
25 EWS (22q12) - Break Apart Probe
26 Angiomatoid Fibrous Histiocytoma Author Recurrence Metastasis Death Enzinger (1979) 46% 21% 13% Costa (1990) 12% 5% 1% Fanburg-Smith (1999) 2% 1% 0%
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28 Case History 15-year-old boy with a deeply situated 4.6 cm mass of the calf region Present for at least four years and slowly growing
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33 Ancillary Studies FUS (16p11) intact S100 protein - SMA - FUS (16p11) translocated Desmin - AE1/AE3 - CD34 - FUS (FISH) +
34 Diagnosis Low-Grade Fibromyxoid Sarcoma (Evans tumor)
35 Myxoid Soft Tissue Lesions Benign Nodular fasciitis Myxoma intramuscular juxta-articular cutaneous Nerve sheath tumors neurofibroma neurothekeoma schwannoma Malignant Myxoid liposarcoma Myxofibrosarcoma (myxoid MFH) Myxoid chondrosarcoma Low-grade fibromyxoid sarcoma All other sarcomas
36 Myxoid Soft Tissue Tumors Morphology is most useful Cellularity and cellular arrangement Atypia Vascular pattern Limited use of IHC (S100) FISH extremely useful
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43 LGFMS Originally described by Harry Evans in 1987 (n=2) Both originally diagnosed as benign Both locally recurred and eventually metastasized One patient died from disease Follow-up study by Evans in 1993 (n=10) 10 new cases 8/10 diagnosed retrospectively after recurrence / metastasis 7/10 recurred 5/10 metastasized (some late) 4/10 died of disease
44 LGFMS: Characteristic bland histology, frequently misdiagnosed as benign Paradoxically aggressive behavior 68% local recurrence 41% metastases 18% died of disease Some cases with increased cellularity and atypia The important feature of this neoplasm is that, despite its banal morphology, as many as 50% of cases eventually metastasize and pursue a fatal clinical course over a period of years. (CDM Fletcher, 2000)
45 Hyalinizing Spindle Cell Tumor with Giant Rosettes (HSCT) Described by Lane et al in 1997 (19 cases) Giant collagen rosettes with surrounding epithelioid cells Focal areas resembling LGFMS Benign behavior (1 recurrence; no mets) Very few cases subsequently reported, including metastatic cases
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47 LGFMS / HSCT Folpe et al (2000) N = 73 cases 70/73 initially diagnosed correctly 3/73 with metastasis, previously diagnosed with benign tumors
48 No sex predilection LGFMS / HSCT Occur at any age but usually in young adults Most common in deep soft tissues of proximal extremities and trunk Often large, slowly growing May have long pre-biopsy duration Folpe et al, AJSP 2000
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53 LGFMS / HSCT S100 - CD34 - Bcl-2 - CD99 - SMA - EMA +/-
54 MUC4 in LGFMS LGFMS (all FUS+) 49/49 (100%) Marked hypercellularity 7/7 Giant collagen rosettes 3/3 HPC-like vessels 4/4 Focal epithelioid morphology 3/3 Focal marked pleomorphism 2/2 Doyle LA et al. AJSP 2011; 35:733-41
55 MUC4 in LGFMS Tumor MUC4 + Cellular myxoma 0/20 Desmoid fibromatosis 0/20 DFSP 0/20 Low-grade MPNST 0/20 Myxofibrosarcoma 0/40 SFT 0/20 Soft tissue perineurioma 0/40 Monophasic synovial sarcoma 6/20 (30%)
56 LGFMS / HSCT Clinical Behavior Follow-up: mos (mean: 38 mos) Local recurrence: 5/54 (9%) Metastasis: 3/54 (6%) Died of disease: 1/54 (2%) Folpe et al. AJSP, 2000
57 Differential Diagnosis Collagenous Tumors Fibromatosis Desmoplastic fibroblastoma (collagenous fibroma) Neurofibroma Perineurioma
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62 Differential Diagnosis Myxoid Tumors Intramuscular myxoma Myxofibrosarcoma ( myxoid MFH )
63 Intramuscular Myxoma Uniformly myxoid Hypocellular, bland spindled cells with pyknotic nuclei Hypovascular Splays apart surrounding skeletal muscle
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65 Myxofibrosarcoma ( Myxoid MFH ) Multinodular, subcutis, older patients More atypical spindled / stellate cells Curvilinear thick-walled vessels with perivascular hypercellularity Less cellular bland areas; more cellular pleomorphic areas
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67 LGFMS / HSCT t(7;16)(q33;p11) t(11;16)(p11;p11) CREB3L2/FUS CREB3L1/FUS
68 Myxoid/Round Cell Liposarcoma Cytogenetics t(12;16)(q13;p11) t(12;22)(q13;q12) DDIT3 (CHOP)/FUS DDIT3 (CHOP)/EWSR1
69 Extraskeletal Myxoid Chondrosarcoma Cytogenetics t(9;22)(q22;q12) t(9;17)(q22;q11) NR4A3/EWSR1 NR4A3/TAF2N
70 Myxoid Soft Tissue Tumors Tumor Defect Genes Myxoma activating GNAS mutations LGFMS/HSCT t(7;16)(q33;p11) CREB3L2/FUS t(11;16)(p11;p11) CREB3L1/FUS MLS/RCLS t(12;16)(q13;p11) DDIT3/FUS t(12;22)(q13;q12) DDIT3/EWSR1 ESMCS t(9;22)(q22;q12) NR4A3/EWSR1 t(9;17)(q22;q11) NR4A3/TAF2N MyxoFS None characteristic
71 LGFMS / HSCT: Summary Sarcoma of children and young adults Deep soft tissues of proximal extremities Deceptively bland histologic features Overlapping features between LGFMS/HSCT Characteristic molecular alteration t(7;16) Treatment: complete excision with tumor-free margins Outcome: low rate of recurrence and rare late metastases
72 Case History 76-year-old male with a history of Barrett s esophagus
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77 Diagnosis High-grade dysplasia with marked architectural distortion, cannot exclude intramucosal adenocarcinoma, arising in the setting of Barrett s esophagus
78 Barrett s Esophagus ACG Definition A change in the esophageal epithelium of any length that can be recognized at endoscopy confirmed to have intestinal metaplasia by biopsy Sampliner RE et al. Am J Gastroenterol 2008
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84 Barrett s Esophagus Cancer: Risk Factors Age (elderly) Epithelium type (IM) Sex (males) Dysplasia Race (Caucasians) Length
85 Barrett s Esophagus Dysplasia: Definition Neoplastic epithelium that remains confined within the basement membrane not synonymous with atypical unlikely to spontaneously regress Both a marker and the precursor of adenocarcinoma
86 Barrett s Esophagus Dysplasia Negative for dysplasia Positive for dysplasia Low-grade High-grade Indefinite for dysplasia
87 Barrett s Esophagus The Problem With Dysplasia Sampling error Diagnostic interpretation reactive vs dysplastic low-grade vs high-grade high-grade vs intramucosal cancer
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90 Barrett s Esophagus & Dysplasia Rules To Live By Dysplasia is recognizable at low magnification (hyperchromatic) Baseline atypia of Barrett s mucosa (regenerative zone) Hold out for cytologic atypia on surface epithelium Be wary of active inflammation Don t use indefinite for dysplasia as a crutch
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92 Barrett s Esophagus & Dysplasia Rules To Live By Dysplasia is recognizable at low magnification (hyperchromatic) Baseline atypia of Barrett s mucosa (regenerative zone) Hold out for cytologic atypia on surface epithelium Be wary of active inflammation Don t use indefinite for dysplasia as a crutch
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95 Barrett s Esophagus & Dysplasia Rules To Live By Dysplasia is recognizable at low magnification (hyperchromatic) Baseline atypia of Barrett s mucosa (regenerative zone) Hold out for cytologic atypia on surface epithelium Be wary of active inflammation Don t use indefinite for dysplasia as a crutch
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98 High-Grade Dysplasia Management Options Surveillance EMR Ablation Esophagectomy (e.g. RFA)
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100 High-Grade Dysplasia Natural History 1099 patients 79 with HGD without evidence of cancer (34 prevalent/45 incident) 4 with cancer found 75 without detectable cancer within one year within one year 12/75 (16%) developed cancer (mean surveillance: 7.3 yrs) Schnell TG et al. Gastroenterology 2001
101 High-Grade Dysplasia Conclusions Patients with HGD without apparent cancer can be safely followed with frequent endoscopic surveillance with biopsies Provided that 1 year of intensive endoscopic searching ( the hunt ) fails to detect cancer Reserve esophagectomy for those patients with documented cancer Schnell TG et al. Gastroenterology 2001
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104 Results Diagnosis Kappa P-value 95% CI Interobserver agreement HGD 0.47 < Moderate HGD/MAD 0.21 < Fair IMC 0.30 < Fair SMC 0.14 < Poor Downs-Kelly E et al. AJG 2008
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