Dr Agata T Kochman Wishaw General Hospital

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Horace Stevenson
6 years ago
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1 Dr Agata T Kochman Wishaw General Hospital

2 Case E1 84 year old male Symptoms: R shoulder pain CT = thymic mass and (R) LL nodules + (L) lung nodule Clinically metastatic lesions in lung with primary thymic tumour? primary lesions open (R) lung biopsy lower lobe Macro: A: Wedge biopsy of lung 27x20x11mm. A1 1/2. A2 A6 1/1. A/E and B: Shave biopsy of lung 15x10mm with a calcified part. B1 B3 1/1. A/E.

3 Case E1 The biopsy of lung shows small tumour nodules the largest measuring 3.1mms

4 Case E1 The tumour consists of sheets, nests and clusters of fairly uniform cells with round, oval and spindle shaped nuclei with granular chromatin and moderate pink granular cytoplasm No mitoses or necrosis seen The cells show peripheral nuclear palisading

5 Case E1 x20

6 Case E1 EMA

7 Case E1 MNF116

8 Case E1 CD56

9 Case E1 Synapto

10 Case E1 chromogranin

11 Case E1 MNF116/Pancytokeratin negative Epithelial membrane antigen positive TTF1 patchy weak nuclear staining CD56 strongly positive Synaptophysin strongly positive Chromogranin A positive

12 Case E1 HE summary: Several nodular proliferations of neuroendocrine cells that have cytologically bland nuclei and eosinophilic cytoplasm These appear to be associated with scarring and each measure less than 5mm in maximum dimension The MIB1 proliferation index is extremely low (less than 5%)

13 Case E1 Small size of these tumours and the related scarring favours that these represent primary tumourlets rather than metastatic carcinoid tumour The only slight concern with this is the small nodule of tumour (possibly in a lymphatic) at the pleural surface TTF 1 staining is not helpful since this can be positive in neuroendocrine tumours from any site

14 Case E1 Tumorlets are nodular proliferations of neuroendocrine cells that are normally present in the airways Up to 4 mm in diameter in the airway wall (larger tumors are called carcinoids) Often multiple, and usually peripheral, they are characterized by small nests of cells having neurosecretory granules They lack mitoses and cellular atypia; typically, they have a hyalinized, fibroelastic stroma

15 Lymph node metastases have been noted in 4 or 5 cases. One case that was associated with Cushing's syndrome had tumor that metastasized widely In 36 cases, females predominated, 28 to 8, and the average age was 70

16 Case E1 It remains unclear whether material obtained from right lower lobe of lung is representative of the thymic mass and left lung nodule. Whilst a primary or metastatic carcinoid of the thymus is a possibility, other lesions of the thymus cannot be excluded and it is impossible to comment on the nature of the left lung nodule on the basis of this material.

17 References 1. Churg A, Warnock M. Pulmonary tumorlet. A form of peripheral carcinoid. Cancer 1976; 37: Pelosi G, Zancanaro C, Sbabo L, Bresaola E, Martignoni G, Bontempini L. Development of innumerable neuroendocrine tumorlets in pulmonary lobe scarred by intralobar sequestration. Immunohistochemical and ultrastructural study of an unusual case. Arch Pathol Lab Med 1992; 116: D'Agati V, Perzin K. Carcinoid tumorlets of the lung with metastasis to a peribronchial lymph node. Report of a case and review of the literature. Cancer 1985; 55: Miller M, Mark G, Kanarek D. Multiple peripheral pulmonary carcinoids and tumorlets of carcinoid type, with restrictive and obstructive lung disease. Am J Med 1978; 65: Aguayo S, Miller Y, Waldron J Jr, Bogin R, Sunday M, Staton G Jr, Beam W, et al. Idiopathic diffuse hyperplasia of pulmonary neuroendocrine cells and airways disease. N Engl J Med 1992; 327:

19 Case E2 84 year old female Torted large left ovarian cyst, normal Ca125 TAH&BSO+omenctectomy done Left ovarian cyst, 220x135x120mm, attached to fallopian tube, 125x5mm and haemorrhagic broad ligament. The cyst is multilocular but the capsule is intact. There are some serosal nodules under the intact capsule, largest 50mm

20 Case E2 The serosal nodules consist mainly of a mixture of invasive moderately differentiated mucinous cystadenocarcinoma mixed with invasive malignant transitional cell tumour containing abnormal mitoses Cystic tumour consists of well differentiated mucinous cystadenoma The non cystic component consists of benign transitional epithelium mixed with benign mucinous cystadenoma

21 Case E2 x4

22 Case E2 x10.

23 Case E2 x40 The mucinous cystadenocarcinoma shows small foci of ciliated serous differentiation.

24 Case E2 CEA

25 Case E2 Ca125

26 Case E2 CK20

27 Case E2 Ca19.9

28 Case E2 CK7 Positive in all tumour components CK20 Negative CEA Positive CA125 Positive in the non transitional mucinous component CA19.9 Positive WT1 Negative CDX2 Negative P53 Protein Negative TTF1 Negative

29 Case E2 Within the left ovarian cystic mass there is evidence of a benign Brenner tumour with accompanying mucinous differentiation In addition, there are small more solid areas of partly necrotic and poorly preserved tissue where there is frank evidence of malignancy

30 Case E2 In addition, the malignant epithelial element shows a variety of patterns of differentiation including areas of mucinous differentiation and areas of serous differentiation Technically this tumour would fall into the category of a malignant mixed epithelial tumour As the major component is actually made up of transitional cell epithelium the tumour has been classified as a malignant Brenner tumour with a minor component of mucinous and serous carcinoma

31 Case E2 A malignant Brenner tumor is a rare form of invasive epithelial ovarian cancer The histologic appearance of malignant Brenner tumor is similar to that of transitional cell cancer of the ovary and transitional epithelium of the urinary bladder Immunohistochemical staining of malignant Brenner tumor often demonstrates positivity for uroplakin III, thrombomodulin and cytokeratin 7 and negativity to cytokeratin 20 The mainstay of treatment is surgical resection, but the exact regimen and benefit of adjuvant therapy remain unknown

32 Case E2 Surface epithelial stromal tumours are the most common neoplasms of the ovary and they encompass five distinct subtypes including serous, mucinous, endometrioid, transitional and the clear cell types, which mostly occur in the pure form In some cases however, two or more subtypes reside within the same tumour. These are known as mixed surface epithelial stromal tumours The WHO has classified mixed tumours as those in which the minor component is easily recognizable and they account for at least 10% of the entire tumours on microscopic examination Mixed epithelial tumours of the ovary comprises less than 4% of all the ovarian epithelial stromal neoplasms; malignant, mixed epithelial tumours are still rarer; most frequent: serous and endometrioid, the serous and transitional cell carcinoma and the endometrioid and clear all carcinoma types

33 Case E2 A. Uterus, endometrium benign polyps cystic glandular hyperplasia. Left ovary combined mucinous cystadenocarcinoma, Grade 2 and malignant Brenner s tumour ex combined mucinous cystadenoma and benign Brenner s tumour. PT1aNxMx. FIGO stage IA. Right ovary serosal adhesion no tumour seen. B. Omentum normal Brenner s tumours are sometimes related to endometrial hyperplasia, as in this case. Post op: Bowel obstruction

34 References: 1. Lee KR, Tavassoli FA, Prat J, Dietel M, Gersell DJ, Karseladze AI, et al. Tumours of the ovary and the peritoneum: surface epithelial stromal tumours. In: Tavassoli FA, Devilee P eds.world Health Organisation Classification of Tumours of the Breast and Female Genital Organs. Lyon: IARC Press; 2003; Prat J. Ovarian endometrioid clear cell, Brenner s and rare epithelial stromal tumors. In Robboy JS, Mutter LG editor s Robboy s Pathology of the Female Reproductive Tract. 2nd edition.elsiever Churchill Livingstone; 2009; Eichhorn JH, Yong RH. Transitional cell carcinoma of the ovary: a morphologic study of 100 cases with emphasis on differential diagnosis. Am J Surg Pathol 2004 Apr; 28 (4): Balasa RW. Adcock LL, Prem KA, Dehner LP. The Brenner tumur, a clinicopathologic review. Obstet Gynecol 1977; Jul, 50 (1):

35 E3 Dr Hasan Vazir Altnagelvin

36 E3 Female, 32 years Diplopia and enlarged pupils for two months Left medial rectus muscle biopsy

41 Diagnosis Amyloid National Amyloid Centre, University College London Medical School, confirmed amyloid and positive staining with Congo Red. They carried out immunohistochemical studies antibodies to serum amyloid A protein (SAA), kappa and lambda light chains. The amyloid did not stain with any of these antibodies. Interpretation: Amyloid of non AA type The possibility of AL amyloid could neither be excluded nor confirmed by present immunohistochemical analyses, as approximately 20% of AL does not stain with antibodies against either kappa or lambda light chains.

42 In March 2010 the patient did not have macroglossia and no organomegaly was detected on abdominal palpation. It was concluded at that time that the patient did not have systemic amyloidosis She has localized orbital AL amyloidosis involving the medial rectus muscle. She is currently on follow up with no active intervention, which was a decision arrived at with after discussion with the patient.

43 34E4 Dr Hasan Vazir Altnagelvin

44 E4 Female, 50 years Large left ovarian cyst Normal CA125 This lady presented with a large ovarian cyst and dense adhesions with evidence of endometriosis (clinical).

54 E4 Both ovaries contain endometriotic cysts. In the left ovary are foci resembling Arias Stella effect. In several sections, there is a small neoplasm composed of glands widely separated by abundant fibrous stroma. This small lesion seems to emanate from the endometriotic cyst

55 E4 In areas, the glands are obviously endometrioid but elsewhere have more nuclear atypia with clear cytoplasm and even some signet ring cells. I do not feel the morphological features are typical of clear cell neoplasm I regard this as an endometrioid neoplasm. Although there are some worrying and unusual features, I would be reluctant to make a diagnosis of an adenocarcinoma.

56 E4 This is best regarded as an unusual borderline endometrioid adenofibroma arising from an ovarian endometriotic cyst. Since the capsule was ruptured, it is regarded as FIGO stage 1C.

57 Circulation 34 Educational case 5 F82 Large lump L breast, clinically malignant. Large volume core biopsy as therapeutic procedure H and E, ER, Ck5/6, S100 available digitally

61 ER

62 CK 5/6

63 S 100

64 Diagnosis Microglandular adenosis

65 Questionnaire Forms returned 59 Attempted case 54 Offered a diagnosis 26 No diagnosis offered 28

66 Diagnoses Microglandular adenosis 19 Adenomyoepithelioma 4 Tubular carcinoma 2 Myoepithelial lesion? Adenosis? 1

67 Problems Could not get access at all Access problematically slow Access blocked by hospital Stuck at registration page Hassle with Flash Player etc

68 NHS IT Least Satisfactory Only 4 of 23 people using NHS IT were able to offer a diagnosis

Mody. AIS vs. Invasive Adenocarcinoma of the Cervix

Mody. AIS vs. Invasive Adenocarcinoma of the Cervix Common Problems in Gynecologic Pathology Michael T. Deavers, M.D. Houston Methodist Hospital, Houston, Texas Common Problems in Gynecologic Pathology Adenocarcinoma in-situ (AIS) of the Cervix vs. Invasive