Educational Cases EQA November T.J. Palmer Raigmore Hospital Inverness

Transcription

1 Educational Cases EQA November 2013 T.J. Palmer Raigmore Hospital Inverness

2 Case 2 Clinical Details Dob 11 February 1951 PMH: 1964 Extraction of 45 aet 13 yr 1966 Cyst between 44 and 46 enucleated 1973 Oblique Xray showed partial resolution of cyst HOPC Lump found on lingual aspect of R body in region Xray showed lucency in bone

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9 Diagnosis Recurrent ameloblastoma Submucosal lump also ameloblastoma 1964 sample reviewed: ameloblastoma unicystic, mural type

10 Odontogenic lesions Odontogenic epithelium Odontogenic mesenchyme Dental hard tissues Dentine Enamel

11 How to recognise odontogenic epithelium? Basaloid cells Cords/islands Nuclei orientated perpendicular to basement membrane Reverse polarity of nuclei situated at pole away from bm.

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16 Presentation Mandibular > maxilla Posterior > anterior With or without absent tooth Dentigerous relationship to tooth (ie attached at dentino-enamel junction) Radiologically look like dentigerous cyst Beware effect of inflammation

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21 CD56

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24 Ameloblastoma Central Unicystic Mural Intraluminal nodule Conventional Follicular Plexiform Acanthomatous/squamous Peripheral

25 Adamantoid tumour x1 Ameloblastic fibroma x9 Ameloblastoma x48 Desmoplastic ameloblastoma x4 Calcifying epithelial odontogenic tumour (Pindborg) x1 Cementoma x1 Dentigerous cyst x1 Keratocyst x4 Necrotizing sialometaplasia x2 Odontogenic fibroma x7 Odontogenic keratocyst x4 Radicular cyst x3 Squamous odontogenic tumour / carcinoma x2 Yes, recurrence x1 No diagnosisx5

26 Behaviour Unicystic Intraluminal good, with no risk of recurrence Mural guarded, especially if budding of basal layer and satellite lesions. Consider re-excision Conventional/Peripheral Local recurrence if not completely excised More aggressive if breach of cortical bone

27 Clinical details Case 1 Female 72 years Left parotid mass recent FNA. VIIn intact and no symptoms of malignancy Gross: Parotid, 22 x 25 x 30mm. c/s shows two adjacent yellow well circumsribed nodules 7 and 15 mm diameter

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35 CK7 CK14

36 SMA CK7

37 Epithelial-myoepithelial carcinoma Parotid Two cell types No matrix Infiltrative Distinctive growth pattern, resemblilng intercalated ducts Low grade May be a pattern ex PSA

38 Acinic cell carcinoma x22 Acinic cell tumour x3 Oncocytic adenoma / oncocytoma x20 Epithelial / myoepithelial carcinoma x6 (including 3 variants) Pleomorphic salivary adenoma x5 Adenoma NOS x1 microcystic x1 Lipoadenoma x3 Myoepithelial adenoma, oncocytyc x1 Myoepithelioma, oncocytic? X1 Clear cell adenocarcinoma x2 Myoepithelial carcinoma x2 High grade invasive ductal carcinoma x1 Mucoepidermoid carcinoma, low grade x1 Intercalated duct carcinoma x2 Polymorphous low grade carcinoma x1 Metastatic tall cell variant papillary carcinoma of thyroid No diagnosis x4

39 An approach to salivary tumours Two cell types v. one cell type Epithelium Non epithelium myoepithelial/mesenchymal phenotype Cystic v. solid

40 One cell type or two cell types One cell type: Warthin s Tumour Adenomas (some) Acinic cell carcinoma Mucoepidermoid ca Adenoca (various) Ca ex PSA Two cell types: Pleomorphic adenoma Adenomas (some) Adenoid cystic carcinoma Basal cell adenoca Epithelial-myoepithelial ca

41 Cystic component or solid? Cystic component Warthin s tumour Lymphoepithelial cysts Solid tumours Everything else! Low grade mucoepidermoid carcinoma Tubular/trabecular adenoma

42 Differential diagnostic dilemmas PSA v. Adenoid cystic carcinoma PSA v. adenomas PSA v. epithelial-myoepithelial carcinoma Oncocytic lesions v. acinic cell carcinoma Warthin s tumour v. lymph node

43 PSA v. Adenoid cystic carcinoma PSA Myxochondroid stroma with embedded cells Basement membrane not prominent Squamous differentiation encapsulated A pink/white tumour Adenoid Cystic ca. Tighter tubular, cribriform, or solid groups Basement membrane Mucin in lumena No stromal component Invasive A blue tumour

44 PSA v. adenomas PSA Myxochondroid stroma with embedded cells Basement membrane not prominent Squamous differentiation Cystic change rare Spindle cell component Adenomas No myxo-chondroid stroma Basement membrane Cystic component Spindle cells rare Often basaloid/blue cytology

45 PSA v. Epithelial-myoepithelial ca PSA Stromal component Polymorphic appearance Epithelial and myoepithelial cells mixed Single, encapsulated lesion Epithelialmyoepithelial ca Organised pattern Epithelial cells central in group. Uniform sized clusters Basement membrane not a feature Multiple nodules with fibrous septa

46 Oncotytoma v Acinic cell carcinoma Oncocytoma Uniform groups Pink granularity Possibly clear cells No mucinor secretions Possible background multifocal nodular oncocytic hyperplasia Acinic cell carcinoma More variable Secretions Looks more like normal parotid Multiplicity of patterns Acinar (serous/mucinous) Clear cell Thyroid like Lymphoid infiltrate

47 Warthin s tumour v. lymph node Warthin s tumour Oncocytic cells lining spaces Two layers of similar cells Cystic component Variable, bland lymphoid component, possibly germinal centres Lymph node Polymorphous or?lymphoma No cyst Non-salivary material May have occasional ductal/acinar groups

48 EQA 37: Educational Cases Susan Robinson

49 Clinical history E3 F43 Marked cervical and groin lymphadenopathy and drenching sweats. HIV negative. Lymphoma?

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52 Diagnosis Leishmaniasis Leishmania donovani confirmed by by PCR

53 98 Responses 51 Leishmaniasis 20 Histoplasmosis 4 Leishmaniasis or Histoplasmosis 17 Granulomatous lymphadenitis (mixed responses including Leishmaniasis, Histoplasmosis, fungal, bacterial) 1 Granuloma inguinale 1 Toxoplasmosis 1 Rosai Dorfman disease

54 Male, 64 years, pigmented lesion, grown rapidly in 3 months. Diagnosis: Prominent balloon cell change in a malignant melanoma

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60 98 Responses 92 Balloon cell melanoma 3 Balloon cell melanoma arising in naevus 1 Atypical balloon cell naevus? melanoma 2 Collision between renal cell carcinoma and melanocytic lesion