EQA circulation 35 educational cases Dr. A Graham Aberdeen Royal Infirmary
Case E1 Female 52 Polypoid mass right side of cervix, adjacent to os
70 Biphasic lesion 4 No answer 3 Prolapsed tube 2 Endometriosis 2 Endosalpingiosis 2 Angiofibroma Responses 2 Pseudosarcomatous angiofibroma 1 Adenoma malignum / polyp / hamartoma / papilloma
Biphasic lesion breakdown 26 Adenofibroma 20 Adenosarcoma 11 Phyllodes tumour 7 Fibroadenoma 4 Adenomyoma 2 Atypical polypoid adenomyoma
WHO classification Adenosarcoma cervix Biphasic lesion Benign epithelial component Malignant stromal component (increased cellularity / atypia / periglandular cuffing / mitotic activity >2/10hpf) Treated by hysterectomy Adenofibroma cervix Biphasic lesion Stroma lacking atypical features Treated by local excision
Robboy et al / Haines & Taylor Adenofibroma cervix Existence doubted Suggest low threshold for diagnosing adenosarcoma Can t assess whole lesion with local excision Hysterectomy advocated
Preferred diagnosis Adenosarcoma of cervix
Case E2 Female 73 Vulval lesion, clinically sebaceous cyst
45 Ectopic breast 6 Apocrine adenoma 5 No answer 4 Mesonephric lesion 4 Mixed tumour 4 Sweat gland tumour Responses 3 Bartholin s adenoma 2 Microglandular hyperplasia 1 Apocrine Ca / clear cell Ca / hamartoma / pleomorphic adenoma / mucinous adenoma / cystadenoma papilliferum / adenomyoma
ectopic breast tissue breakdown 19 with DCIS 12 with fibrocystic changes 7 NOS 4 with ADH 1 with DCIS and carcinoma 1 with sclerosing adenosis 1 with sclerosed papilloma
CK14
CK14
GCDFP-15
Preferred diagnosis Low grade DCIS in heterotopic breast tissue of vulva
Heterotopic breast tissue of vulva Uncommon Wide spectrum of breast disease described Normal breast Lactational FCC SA DCIS Carcinoma
Case E3
Case E3 Large left neck mass in the region of the thyroid gland. Clinically? Lymphoma? Castleman s disease? Pathology from intra abdominal lesion Five fragments of pale brown tissue up to 12mm in maximum dimension
Thymoma Prominent lymphoid infiltrate Immature T cells, B cells absent / sparse CD3 and other Pan T antigens Co expression of CD4 and CD8 Expression of CD1a and CD99 Tdt positive Very high labelling index with Ki67
Thymoma Cytokeratin stains reveal a meshwork of thymic epithelial cells AE1/3, Cam5.2 CK5/6, CK7, CK 19
Thymoma (B2)
Thymoma Usually arise in anterior mediastinum but: Uncommon tumours Wide age range May extend superiorly to give rise to cervical mass Can arise in ectopic thymic tissue Head and neck region Unusual locations may put you off guard Always include cytokeratin stain in lymphoma IHC panel
Thymoma Tumour of moderate malignancy Greater malignant potential than B1 and less than B3 subtypes Often invasive 5 15% cases non resectable at presentation Recurrences after resection in 5 10% cases 1 7 years until onset but does not preclude survival beyond 10 years Metastases in 10% cases Prognosis dependent upon Stage, suitability for resection 10 year survival of 50% and above quoted may be very high
Case E4
Case E4? infected tissue anterior to right humerus Hard mass of tissue 18 x 15 x 12mm Calcified Bosselated appearing surface Decalcified in formic acid, bisected and all processed for histology
Myositis Ossificans
Myositis ossificans Smooth peripheral shell
Myositis ossificans Most commonly active adolescents and adults Rare in children Common sites are on the limbs For the upper limb flexor compartments most commonly implicated Zonal pattern demonstrated in this case is characteristic May present with features and lab findings (raised plasma viscosity, WCC and alk phosph levels) that suggest inflammation / infection
Myositis ossificans Differential diagnosis Extraskeletal osteosarcoma Reverse of myositis ossificans zoning pattern Cytological features of malignancy Confusion most likely with an early myositis ossificans lesion Rare in young individuals Fibrodysplasia ossificans progressiva Heritable disorder Microdactylia and malformations of hands and feet Usually affects muscles of shoulder girdle, neck and back Fibro osseous pseudotumour of the digits Lacks zonal pattern of myositis ossifcans