South East England General Histopathology EQA Scheme
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1 South East England General Round a Final Case Analyses Cases 635 to 646 Circulated January February responses (89.73%) Prepared April 2016 Authorised by: Prof J Schofield Date: 19/4/2016 With thanks to those who contributed to this round: TRUSTS CPA/ISO NUMBERS Kingston Hospital NHS Foundation Trust 8132 Frimley Park Hospital NHS Foundation Trust 1214 East Sussex Healthcare NHS Trust Surrey & Sussex Healthcare NHS Trust 1814 Basildon & Thurrock University Hospitals NHS Foundation Trust 7882 Ashford & St Peter's NHS Foundation Trust Maidstone & Tunbridge Wells NHS Trust 3060 Queen Victoria Hospital NHS Foundation Trust 8238 Western Sussex Hospitals NHS Foundation Trust East Kent Hospital University Foundation Trust 899 Document title: Final Case Analysis template Page 1 of 13
2 Case Number: 635 Diagnostic category: GI Tract Clinical: F55. Tumour left parotid. Superficial parotidectomy. Specimen: Left parotid tumour Macro: 13g salivary gland with a well circumscribed tumour 18mm in max dimension. 1 Mucoepidermoid carcinoma Mucinous cystadenoma Mammary analogue secretory carcinoma Mucous cyst 0.01 Most popular diagnosis: Mucoepidermoid carcinoma Reported Diagnosis: Low grade (well differentiated) mucoepidermoid carcinoma Document title: Final Case Analysis template Page 2 of 13
3 Case Number: 636 Diagnostic category: GU Clinical: F60. Right kidney. Radical nephrectomy for mass. Specimen: Right kidney Macro : Nephrectomy specimen w g and m. 170 x 115 x up to 45mm. Slicing shows a well circumscribed cystic tumour mass 60mm in diameter. 1 Papillary Renal cell carcinoma Renal cell carcinoma/clear cell ca 0.61 Most popular diagnosis: Papillary Renal cell carcinoma Reported Diagnosis: Papillary renal cell carcinoma Document title: Final Case Analysis template Page 3 of 13
4 Case Number: 637 Diagnostic category: Breast Clinical: F42. 22mm lobulated hypoechoic mass UOQ left breast. A few other rounded similar nodules seen medially. Hypervascular - imaging indeterminate, U3 Specimen: Breast Macro: Fibrofatty tissue 60mm x 50mm x 40mm with a well circumscribed tumour 20mm diameter. 1 Borderline/Malignant Phyllodes tumour Phyllodes tumour NOS Benign Phyllodes tumour Carcinosarcoma Fibroadenoma (with hybrid features of intraductal papilloma) 0.08 Most popular diagnosis: Borderline/Malignant Phyllodes tumour Reported Diagnosis: Malignant phyllodes tumour Document title: Final Case Analysis template Page 4 of 13
5 Case Number: 638 Diagnostic category: Skin Clinical: M44.?Sebaceous naevus post-auricular region left side. Specimen: Skin Macro: Ellipse of hair-bearing skin 30 x 17mm, depth 4mm. The surface is mostly covered by a focally ulcerated, multinodular plaque 20 x 13mm. 1 Syringocystadenoma papilliferum (and sebaceous naevus) Sebaceous naevus Papillary hidradenoma Other benign entity / eccrine spiradenoma Benign adnexal tumour?trichoepithelioma Benign sweat duct tumour possibly arising with naevus 0.08 sebaceous 7 Naevus sebaceous with apocrine, sebaceous & syringomatous 0.08 elements 8 Warty dyskeratoma Focal acantholytic dyskeratoma 0.02 Most popular diagnosis: Syringocystadenoma papilliferum (and sebaceous naevus) Reported Diagnosis: Organoid naevus with syringo cystadenoma papilliferum Document title: Final Case Analysis template Page 5 of 13
6 Case Number: 639 Diagnostic category: Gynae Clinical: F39. Left ovarian cyst. Specimen: Ovarian cyst Macro: Thin walled cyst 120 x 100 x 75mm. Slicing reveals three locules with a thickened area at one edge 30mm across. 1 Mature cystic teratoma / dermoid cyst Most popular diagnosis: Mature cystic teratoma / dermoid cyst Reported Diagnosis: Mature cystic teratoma (dermoid cyst) Document title: Final Case Analysis template Page 6 of 13
7 Case Number: 640 Diagnostic category: Miscellaneous Clinical: M46. Lesion helix left pinna?chondrodermatitis Specimen: Skin Macro: Piece of skin 13 x 5 x 3mm. 1 Gout / Tophus / Urate Pseudocyst Chondrodermatitis nodularis helicus chronica Ochronosis Neurothekoma (dermal nerve sheath myxoma) Focal cutaneous mucinosis Granuloma annulare Necrotizing infundibular crystalline folliculitis Rheumatoid nodule 0.08 Most popular diagnosis: Gout / Tophus / Urate Reported Diagnosis: Gout (Granulomatous Inflammation) Document title: Final Case Analysis template Page 7 of 13
8 Case Number: 641 Diagnostic category: Respiratory Clinical: M75. Two PET avid lesions in left upper lobe but no tissue diagnosis?primary lung cancer,? Specimen: Lung Macro: Left upper lobe weighing 290g before inflation and measuring 18 x 10 x 6.5cm. Near the apex there is a white nodule with ill defined borders, measuring 2 x 1.3 x 1.5cm. Immuno: CK7, TTF1 and synaptophysin positive; CK20 and chromogranin A negative. Ki67 index is high (80%). 1 Small cell ca / neuroendocrine carcinoma Atypical carcinoid Basaloid carcinoma 0.08 Most popular diagnosis: Small cell ca / neuroendocrine carcinoma Reported Diagnosis: Poorly differentiated neuroendocrine carcinoma Document title: Final Case Analysis template Page 8 of 13
9 Case Number: 642 Diagnostic category: Lymphoreticular Clinical: 34F. Enlarging nodes right side of neck. Known previous sarcoidosis. No symptoms. Specimen: Subcutaneous tissue Macro: A previously incised lymph node measuring up to 25mm. Caseous material contained within. PAS & ZN stains negative 1 Branchial cleft cyst/lymphoepithelial cyst & sarcoid / 8.20 granulomata 2 Epidermoid cyst and sarcoidosis Simple squamous cyst and sarcoidosis Metastatic SCC with sarcoid Branchial cleft cyst only Sarcoid / granulomata only Sarcoid and epidermal inclusion Branchial cyst with granulomas c/w TB Lymphoepithelial cyst 0.04 Most popular diagnosis: Branchial cleft cyst/lymphoepithelial cyst & sarcoid / granulomata Reported Diagnosis: Branchial cyst with sarcoidosis Document title: Final Case Analysis template Page 9 of 13
10 Case Number: 643 Diagnostic category: Endocrine Clinical: F75. Complex solid nodule thyroid right lobe. Specimen: Thyroid Macro: A lobe of thyroid measuring 65mm x 35mm x 20mm. Slicing reveals a circumscribed lesion measuring 25mm with a thick capsule. 1 (Various) adenoma Follicular carcinoma Hurthle cell tumour with microinvasion Follicular neoplasm (with uncertain malignant potential Vascular Invasion) 0.08 Most popular diagnosis: (Various) adenoma Reported Diagnosis: Follicular adenoma Document title: Final Case Analysis template Page 10 of 13
11 Case Number: 644 Diagnostic category: Miscellaneous Clinical Specimen : F52.?epidermoid cyst inner thigh. : Cyst inner thigh Macro : Yellow piece of tissue 15 x 10 x 5mm 1 Steatocystoma simplex / multiplex Dermoid cyst Benign cystic adnexal tumour Hidrocystoma Epidermoid cyst 0.01 Most popular diagnosis: Steatocystoma simplex / multiplex Reported Diagnosis: Steatocystoma multiplex Document title: Final Case Analysis template Page 11 of 13
12 EDUCATIONAL CASE Case Number: 645 Diagnostic category: Educational Clinical : F77. Lesion left forearm recurrent BCC. Previous removal Specimen : Skin biopsy Macro : An ellipse of skin 36 x 27 x 12mm. There was a longitudinal scar on the surface 20mm in length. Serial slicing showed an ill-defined firm grey gritty tumour within the dermis. Suggested diagnoses: Merkel cell carcinoma, but needs appropriate IHC Merkel cell carcinoma Neuroendocrine, Merkel cell, carcinoma of skin Basal cell carcinoma Small cell carcinoma Poorly differentiated neuroendocrine carcinoma in keeping with Merkel cell carcinoma. Immunos required. Poorly differentiated malignancy Recurrent microcystic adnexal carcinoma Merkel cell recurrence Adenoid cystic carcinoma High grade neuroendocrine carcinoma Adenoid cystic carcinoma. Most likely metastasis from salivary gland origin. Basaloid squamous cell carcinoma Spiradenocarcinoma Micronodular basal cell carcinoma Neuroendocrine/Merkel cell carcinoma High grade neuroendocrine carcinoma,?primary?secondary Metastatic basaloid carcinoma Metastatic adenocarcinoma Metastatic neuroendocrine carcinoma Skin forearm adenoid cystic carcinoma High grade neuroendocirine carcinoma Neuroendocrine tumour? Basaloid SCC need immuno Met Neuroendocrine tumour Merkel cell carcinoma but has to exclude metastasis Neuroendocrine carcinoma (Merkel cell carcinoma) Immunos to confirm: CK20, Cam5.2, synaptophysin Adenoid cystic carcinoma PAS/Alcian blue, EMA, CEA Adnexal carcinoma Poorly differentiated carcinoma with duct formation,?adnexal (eg eccrine or adenoid cystic) +/- merkel cell carcinoma Not Basal cell carcinoma a poorly differentiated carcinoma with neuro endocrine features, suggestive of Merkel cell carcinoma Eccrine ca Poorly differentiated carcinoma, we need to exclude metastatic tumour, then primary Merkel cell tumour Vs poorly differentiated adnexal carcinoma Metastatic carcinoma, including small cell carcinoma and breast carcinoma Merkel cell carcinoma presumed recurrent Sweat gland carcinoma Metastatic small cell carcinoma of the lung Infiltrating sclerosing basal cell carcinoma Not BCC but invasive carcinoma Merkel cell carcinoma, provided dot-like CK20+, negative for TTF-1 and positive for CD56, Synaptophysin, Chromogranin and CAM5.2. IHC for Merkel cell polyoma virus + Reported diagnosis: Recurrent basal cell carcinoma - but subsequently shown to be adenoid cystic carcinoma metastasis from nasal sinus when this finally presented 5 years later. Document title: Final Case Analysis template Page 12 of 13
13 EDUCATIONAL CASE Case Number: 646 Diagnostic category: Educational Clinical Specimen : M74. GI bleeding. : Gastric polyp Macro : Dark brown polyp 28 x 21 x 16mm with a uniform cut surface. Immuno: Positive for HMB45, S100, Melan A, CD117. Occasional cells positive for CAM 5.2, Negative for CD34, AE1/3, SMA, Chromogranin and Synaptophysin. Pigment is positive with Masson Fontana and negative with Perls. Suggested diagnoses: Melanoma (primary vs metastatic) (probably metastatic) malignant melanoma Malignant melanoma, probably primary disease Malignant melanoma Melanoma Malignant melanoma probably metastatic to gastric mucosa Melanoma in a hyperplastic polyp Metastatic melanoma into a fundal polyp Melanoma of stomach,?primary or secondary Melanotic schwannoma Melanoma in a gastric polyp (fundic) Malignant melanoma most likely primary but secondary to the site has to be excluded Melanoma arising on a gastric fundic gland polyp Malignant melanoma in a hyperplastic polyp Fundic gland polyp with malignant melanoma Cd117+melanoma Malignant melanoma, exclude metastasis before considering as a primary Melanoma presumed secondary primary not excluded Metastatic melanoma within a hyperplastic polyp: probably metastatic Stomach, polyp excision malignant melanoma (metastatic) Metastatic malignant melanoma in a hyperplastic gastric polyp Melanoma in a pyloric gland adenoma Primary Gastric Malignant Melanoma Reported diagnosis: Primary gastric melanoma. Metastases should be excluded. Document title: Final Case Analysis template Page 13 of 13
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