my personal experience at university of toronto and recent u · 2015-10-08 · my personal...
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My personal experience at University of Toronto and recent updates of
Endocrine Pathology Toshitetsu Hayashi M.D. Ph.D.
¹Department of Diagnostic Pathology, Takamatsu Red Cross Hospital, Japan
²Laboratory Medicine & Pathobiology, University of Toronto, Faculty of Medicine, Canada
Date of Presentation: Oct 5th 2015
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Presentation Overview
Participants should have an understanding of:
I) Brief report and feed back of my personal experience at University of Toronto
II) Recent update of endocrine pathology (pituitary, thyroid, parathyroid, adrenal gland, neuroendocrine tumors)
III)Application to the routine practice and
clinical-pathological correlation
Recent update of endocrine pathology
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Preparatory steps
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The adventure begins at this way
Send-off party
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Section of Endocrine Pathology
Members of the section of Endocrine Pathology:
* 3 consultants (board certified pathologists)
* 1 clinical fellow, residents doing rotation or
medical students
Research team:
*Laboratory: 12 scientists or research fellows
Toronto General Hospital
Dr. METE Dr. WinerProf. Dr. Asa
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With specialist (board)
license of home-country:
Academic license
(restricted license):
University Hospital
Medical
license
examination
心
International medical graduates
BOARD
EXAM
Clinical fellow/ Staff pathologist
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I) Pituitary gland
Recent update of endocrine pathology
New concepts and approach for pituitary tumors
I)Adequate use of immunohistochemistry (panel of transcription factors and hormones for accurate classification)
II) New classification scheme for pituitary adenomas
III) Spindle cell oncocytomas and granular cell tumors of the pituitary are variants of pituicytoma
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I) Pituitary gland
Recent update of endocrine pathology
* Reticulin and PAS stains
Immunohistochemistry panel for pituitary adenomas
* Transcription factors: PIT-1, T-PIT-1 (N/A), SF-1* GH, TSH, FSH, LH, TSH, ER, ACTH, Alpha-HCG* FGFR-4* MIB-1* CAM 5.2 (LMWCK)
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I) Pituitary gland
Recent update of endocrine pathology
New concepts and approach for pituitary tumors
I) Adequate use of immunohistochemistry (transcription
factors and hormones for accurate classification)
II) New classification scheme for pituitary adenomas
III) Spindle cell oncocytomas and granular cell tumors of the pituitary are variants of pituicytoma
Feed-back for Kagawa University
I) Acquisition of CAM 5.2 antibody and other hormones (SF-1)
II) Beware of aggressive variants, corticotroph adenomas and Crooke- hyaline change in non-tumoral part
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II) Thyroid and parathyroid gland
Recent update of endocrine pathology
A) New concepts and approach for thyroid tumors
I) WHAFFT
II) Papillary thyroid carcinoma (PTC): new definition
III) Controversial thyroid capsule: Extrathyroidal
extension (ETE; pT3)Dr. METE
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Needle tract
I) WHAFFT? WHAT????????(Worrisome Histologic Alterations Following Fine needle aspiration of the Thyroid)
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Papillary thyroid carcinoma (PTC)
Nuclear membrane enlargement and irregularities Nuclear grooving
Intranuclear pseudoinclusion Thick colloid with scalloped appearance
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How to make diagnosis of PTC?
Dr. METE
First of all: nuclear enlargement and irregularities
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Dr. METE
Dr. ASA
Dr. EZZAT
Endocrine rounds: 4/month
Princess Margaret Hospital (Cancer Center)
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IIb) Parathyroid gland
Recent update of endocrine pathology
Challenges of parathyroid pathology
I) Hyperplasia vs. adenoma
II) Adenoma (especially post-FNA) vs. atypical adenoma
vs. parathyroid carcinoma Staff of the Endocrine Pathology ServiceDr. METE and WINER (Holiday Party)
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IIb) Parathyroid gland
Recent update of endocrine pathology
Challenges of parathyroid pathology
I) Hyperplasia vs. adenoma
II) Adenoma (especially post-FNA) vs. atypical adenoma
vs. parathyroid carcinomaAfter the removal of an abnormal parathyroid gland
*Adenoma: a drop of intraoperative PTH >75%*Hyperplasia: much lower
*Biochemical and morphological correlation is required.
Dr. METE
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IIb) Parathyroid gland
Recent update of endocrine pathology
When can the diagnosis of parathyroid carcinoma be
rendered?
I) Clinical diagnosis (distant metastasis or gross
invasion at the moment of surgery)
II) Morphological diagnosis: invasion of surrounding
structure, vascular invasion, perineural invasion
II) Immunohistochemical diagnosis
III) Molecular diagnosis: DNA methylation profile,
HRPT2 gene mutation
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Left common carotid arteryBrachiocephalic artery
Atypical adenoma (adenoma
with atypical features)Parathyroid carcinoma
P27(+) P27(-).
Bcl-2 (+) Bcl-2(-)
MDM2(+) MDM2(-)
Rb(+; preserved), Cyclind D1(+) Rb(-), Cyclin D1(-)
Parafibromin(+) Parafibromin(-)
Galectin 3(-) Galectin 3(+)
Low Ki-67, p53 High Ki-67(according to Papotti et al;
>6%), p53
Immunohistochemistry panel for parathyroid tumors
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II) Thyroid and parathyroid gland
Recent update of endocrine pathology
A) New concepts and approach for thyroid tumors
I) WHAFFT
II) Papillary thyroid carcinoma (PTC): new definition
III) Controversial thyroid capsule: Extrathyroidal
extension (ETE; pT3)Dr. METE
Feed-back for Kagawa University
I) Close clinical-pathological correlation (scan, hot nodule, previous FNA history)
II) Histology: gold standard + immunostains (HBME-1, CK19) + careful observation of the background
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Hard times (extremely harsh winter of Toronto + α)
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Hang on here, DAD!!!
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III) Adrenal tumor
Recent update of endocrine pathology
New concepts and approach for adrenal tumors
I) Defect and inappropriateness of Weiss criteria
II) Proposal of new diagnostic scheme and protocol
III) Angiogenesis and endocrine tumor
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Modified Weiss criteria for adrenal cortical carcinoma (ACC):*Mitotic rate >5 per 50 high-power fields
*Cytoplasm (clear cells comprising 25% or less of the tumor)
*Abnormal mitoses
*Necrosis
*Capsular invasion
Calculate: 2x mitotic rate criterion + 2x clear cytoplasm criterion + abnormal
mitoses + necrosis + capsular invasion (score of 3 or more suggests malignancy,
Each criterion is scored 0 when absent and 1 when present in the tumor
Reference: Am J Surg Pathol 2002;26:1612
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Modified Weiss criteria:
*Mitotic rate >5 per 50 high-power fields
*Cytoplasm (clear cells comprising 25% or less of the tumor)
*Abnormal mitoses
*Necrosis
*Capsular invasion
Calculate: 2x mitotic rate criterion + 2x clear cytoplasm criterion + abnormal
mitoses + necrosis + capsular invasion (score of 3 or more suggests malignancy,
Each criterion is scored 0 when absent and 1 when present in the tumor
Reference: Am J Surg Pathol 2002;26:1612
Dr. Papotti (University of Torino) Dr. METE (University of Toronto)
It’s unreliable!!!!!!!!!!!(especially for myxoid and
oncocytic variant of adrenocortical carcinoma)
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New proposal and panel of immunohistochemistry for ADRENAL
CORTICAL CARCINOMAS**Diagnostic algorithm: Reticulin stain +
mitosis count + necrosis + vascular invasion
Criteria of malignancy (Histology):
*Low grade carcinomas: mitoses <20/50 HPF
*High grade carcinomas: mitoses >20/50 HPF
Overall features:
*P53>90%
*IGF-2: (+)
*b-catenin: nuclear expression
*Vascular invasion
*Macroscopic invasive tumor
*Atypical mitoses
*Diffuse effacement of reticulin stain (but no evident in borderline cases)
***Rule out metastasis (the most common malignancy of adrenal gland)
Panel of immunostaining: SF-1, Melan A, Inhibin, epithelial markers (usually
negative: EMA, CK7), IGF2, b-catenin (nuclear staining), p53
Aberrant b-catenin expression
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Angiogenesis and endocrine tumors
Recent update of endocrine pathology
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III) Adrenal tumor
Recent update of endocrine pathology
New concepts and approach for adrenal tumors
I)Weakness and inappropriateness of Weiss criteria
II)Proposal of new diagnostic scheme and protocol
II) Angiogenesis and endocrine tumor
Feed-back for Kagawa University
I) Be careful with the modified Weiss criteria for adrenal cortical carcinoma (ACC)II) Immunohistochemical panel for ACC and proposal of the new criteria
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IV) Neuroendocrine tumors (NET)
Recent update of endocrine pathology
New concepts and approach for NET and paraganglioma (PGL)
I) New WHO classification of GEPNET (2010)
II) All NETs are potentially malignant
III) Diagnostic algorithm of paraganglioma
Dr. METE
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Beware of NET: Wolf in sheep’s clothing
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Ref: Hayashi T. et al, Diagnostic histopathology Vol 20:8 Aug 2004 (Review)
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1. Neuroendocrine neoplasms: peculiar tumors with precursor lesions, genetic background and familiar syndromes.
2. Biochemical, clinical and morphological correlation is mandatory for an appropriate diagnosis.
3. Long term following data suggest that all NETs are malignant.
4. Beware and rule out paraganglioma when dealing with cytokeratin and transcription factor negative NET.
Recent update of Endocrine Pathology
Practical points
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A happy ending of my 1 year Canadian program and…
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My adventure continues and………..
Short-term follow up
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Work hard and play hard!
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Guided visit tour of Takamatsu Red Cross Hospital
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