qa conference conf #1, may 23, 2012 by dr. e. ravinsky
TRANSCRIPT
QA CONFERENCEConf #1, May 23, 2012
By Dr. E. Ravinsky
CASE 1
54 year old female Right breast core biopsy Central calcs R/O DCIS Moderate probability Magnification x 4
CASE 1
Magnification x 20
CASE 1
Magnification x 20
Case 1
CASE 1
Magnification x 20
Case 1
Diagnosis Pathologist or resident
ADH versus florid UDH
CK5/6 immuno will help
1 Pathologist
ADH
Do CK5/6 to rule out UDH
1 Pathologist
ADH (at most) 1 Pathologist
Favour UDH over ADH
Consider CK5/6
1 Resident
Fibrocystic change with florid UDH
Do CK5/6
1 Resident
Florid duct hyperplasia 1 Pathologist
High grade DCIS 1 Pathologist
CASE 1
Immunohistochemistry CK5/6
CASE 1
The answer is:Atypical duct hyperplasia
Case 2
50 year old female Right breast core biopsy Calcs lower aspect R/O DCIS Magnification x 2
Case 2
Magnification x 4
Case 1
Magnification x 20
Case 2
Magnification x 10
Case 2
Magnification x 20
Case 2
Diagnosis Pathologist or Resident
ADH 3 Pathologists
1 Resident
Columnar cell hyperplasia with atypia
1 Pathologist
Low grade DCIS 1Pathologist
High grade DCIS
Suspicious for invasion
1 Resident
Case 2
The answer is:Atypical duct hyperplasia
Atypical Duct Hyperplasia
DEFINITION:A proliferative lesion that fulfills
some, but not all, of the features of duct carcinoma in situ
Diagnosis is based on quantitative and qualitative features
Atypical Duct Hyperplasia
Quantitative features:One duct with qualitative features
of DCISDucts with qualitative features of
DCIS less than 2.0 mm across
Atypical Duct Hyperplasia
Qualitative features: Presence of architectural or cytologic features
of DCIS mixed with features of usual duct hyperplasia
Can have a cribriform or solid pattern Can have cytologic atypia
Nuclear enlargement Nuclear hyperchromasia Irregular chromatin pattern Enlarged pleomorphic nucleoli Atypical cells have distinct cell borders
Atypical Duct Hyperplasia Usual duct hyperplasia
Cellular proliferation has a syncytial appearance because individual cell borders are inconspicuous
May have streaming appearance
Microlumens are irregular in size, irregular in shape (slit-like, ovoid, crescentic, serpeginous)
Cells surrounding lumens are not oriented. Ductal cells tend to be parallel to the lumina
Atypical duct hyperplasia Monomorphic population of cells
with distinct cell borders Can have solid growth pattern Can have cribriform growth pattern
in which microlumens are round Ductal cells are oriented radially
around the lumens In columnar cell hyperplasia with
atypia, cells are columnar Atypia is architectural:
Cribriform Cell bridges Roman arches Micropapillary Radial orientation of nuclei
Atypical Duct Hyperplasia
Usual duct hyperplasia: Cytoplasm may be
reduced, giving the cells an increased nuclear/cytoplasmic ratio, but the nuclei are not enlarged
Cell borders are indistinct Cytoplasm is amphophilic
or weakly eosinophilic and homogenous
Cytoplasm may be vacuolated, but true intracytoplasmic lumens are not identified
Atypical duct hyperplasia: Nuclear enlargement
leading to an increased nuclear/cytoplasmic ratio
Nuclear hyperchromasia and an irregular chromatin pattern
Enlarged, pleomorphic nucleoli
Distinct cell borders May have
intracytoplasmic lumena containing muin
Florid Duct Hyperplasia
Case 3
85 Year female Unguided core biopsy
right breast Probable right breast
cancer Large central mass and
clinically positive node Magnification x 4
Case 3
Magnification x 10
Case 3
Magnification x 20
Case 3
Diagnosis Pathologist or Resident
Poorly differentiated malignancy
Ddx: Poorly differentiated carcinoma;lymphoma; melanoma
Immuno will help
1 Pathologist
Favour poorly differentiated carcinoma
Needs immuno
1 Pathologist
1Resident
Needs immuno 1 Pathologist
1 Resident
High grade invasive duct carcinoma
1 Pathologist
Case 3
Immunohistochemistry for CD45
Case 3
The answer is:Lymphoma breast
Lymphoma Breast
Recognizing lymphoma of the breast can be problematic, particularly in a needle core biopsy
Distinguishing large cell lymphoma from poorly differentiated carcinoma can be difficult.
Large cell lymphoma may assume solid, diffuse and sometimes alveolar growth patterns
Another problem is distinguishing lymphoma from lobular carcinoma
Signet-ring cell lymphoma bears a striking resemblance to signet ring cell lobular carcinoma
Lymphoma Breast
It has been noted, that when a tumour is poorly differentiated, the distinction between poorly differentiated carcinoma and high grade lymphoma cannot be made on H+E examination
The tumour cells in this case are large and monotonous with a very high N/C ratio and scant cytoplasm
The cells of high grade carcinoma tend to be pleomorphic with large vesicular nuclei and prominent nucleoli.
Although they have high N/C ratio, they tend to have more cytoplasm than lymphoma cells
Lymphoma Breast
A reactive lymphocytic infiltrate can be identified in association with lymphomas and carcinomas, but it’s presence together with other features can raise the possibility of lymphoma
This is particularly true for infiltrating lobular carcinomas which tend not to be associated with a lymphocytic infiltrate
In summary, we should be alert to the subtle signs that a breast tumour may be a lymphoma
Immunohistochemistry for cytokeratin and CD45 should be performed in all cases where the morphologic features raise the possibility of lymphoma
Lymphoma Breast
Lymphoma Breast (signet-ring)
Lymphoma Breast
Lymphoma breast (angiocentric)
Solid papillary carcinoma
Solid papillary carcinoma
Case 4
Biopsy vulva 52 year old female Labial lesion R/O VIN Magnification x 2
Case 4
Magnification x 10
Case 4
Magnification x 20
Case 4
Magnification x 20
Case 4
Diagnosis Pathologist or Resident
Extramammary Paget disease 1 Pathologist
Paget disease vs melanoma
Needs immuno
2 Residents
2 Pathologists
Paget disease vs melanoma in situ vs squamous cell carcinoma in situ
1 Pathologist
Case 4
The neoplastic cells stain positive on mucicarmine and PAS diastase
Immunohistochemical stain for CEA was done on the biopsy specimen and the neoplastic cells stain positive
Immunohistochemical stains on the excision specimen are positive for CK7 and ER and negative for CK20 and CDX2
Case 4
THE ANSWER IS:Paget disease of vulva
Paget Disease of Vulva
Primary Paget disease (primary cutaneous Paget disease)
Paget disease as an intraepithelial neoplasm/in situ Paget disease
Paget disease as an intraepithelial neoplasm with invasion/invasive primary Paget disease
Paget disease as a manifestation of an underlying cutaneous neoplasm
Secondary Paget disease (Paget disease of non-cutaneous origin)
Paget disease as a manifestation of anal-rectal carcinoma
Paget disease related to other adenocarcinomas
Paget disease as a manifestation of urothelial carcinoma
Staining of Paget disease
Primary Paget disease Paget disease in anal-rectal adenocarcinoma
Paget disease in urothelial carcinoma
CK7+ CK7- CK7+/-
CK20- CK20+ CK20+
CDX2- CDX2+ CDX2+/-
p63- p63- p63+
ER+ ER- ER-
Brst2+ Brst2- Brst2-
Morphology of Paget disease
Paget disease Melanoma VINLocation of tumour cells
Mainly located in the basal and parabasal layers compressing basal keratinocytes. Tumour cells may be present in the upper layers
Located at the dermal-epidermal junction. Tumour cells may be present in the upper layers
Evenly spaced throughout the epidermis singly and in nests
Arrangement of tumour cells
Larger than those of melanoma and have more cytoplasm
May form glandular spaces
Smaller than those of Paget disease and have less cytoplasm
Resemble cells of Paget disease and are large with abundant pale cytoplasm, clear nuclei and prominent nucleoli
PAS + - +
PAS-D + - -
Mucicarmin + - -
Immunohistochemical StainingPrimary Paget Disease Melanoma VIN
Mucin+/- Mucin- Mucin-
CK7+ CK7- CK7+/-
CK20- CK20- CK20-
CEA+ CEA- CEA-
ER+ ER- ER-
Brst2+ Brst2- Brst2-
S100- S100+ S100-
Mart-1- Mart-1+ Mart-1-
HMB45- HMB45+ HMB45-
P63- P63- P63+
P16- P16- P16+
Case 5
25 year old female. ASCUS on recent pap
smear. Colposcopic biopsy of
an erythematous area, Slightly raised, No epithelial changes
Magnification x 2
Case 5
Magnification x 10
Case 5
Magnification x 20
Case 5
Diagnosis Pathologist or Resident
Endometriosis 2 Pathologists
? Endometriosis
Do CD10 (1 pathologist)
2 Pathologists
No malignancy
Edematous stroma with PNMs and tubal metaplasia
1 Resident
Focal moderate squamous dysplasia with stroma a bit hypercellular
1 Resident
Case 5
The answer isEndometriosis of cervix
Endometriosis of cervix Endometriosis of cervix is not uncommon It is usually confined to the superficial third of the
cervical wall They appear as small blue or red nodules on the
cervix Histologically, the glands and stroma resemble
proliferative endometrium The mechanism responsible for the development of
endometriosis is unknown, but it frequently develops following cervical trauma
Cervical endometriosis occurs in 5-43% of patients who have had cautery, cone biopsy or LEEP excisions
Endometriosis of cervix
Endometriosis can be mistaken for AIS The cells of normal proliferating endometrium
are very active They are pseudostratified. They have large
oval nuclei with numerous nucleoli Numerous mitoses are identified
Endometriosis of cervix How to identify endometriosis of cervix:
The glandular cells of endometriosis have an endometriotic appearance with a moderate amount of basophilic cytoplasm and regular oval nuclei
Endometriosis can be recognized by the presence of endometrial-type stroma, but the pathologist must be aware of the possibility or s/he might concentrate on the glands and not notice it
In some cases, there may be abundant hemorrhage and the endometrial-type stroma might not be obvious
The presence of small arterioles like the spiral arterioles can help identify the presence of endometrial-type stroma
CD10 can confirm the endometrioid nature of the stroma
Case 6
37 year old female with 2 ASCUS diagnoses on cervico-vaginal smear
Biopsy cervix taken at colposcopy
Colposcopic impression “?CIN1”
Magnification x 4
Case 6
Magnification x 10
Case 6
Magnification x 20
Case 6
Mangification x 20
Case 6
Magnification x 40
Case 6
Diagnosis Pathologist or Resident
Atypical endocervical epithelium
? Reactive vs in-situ
Do P16, Ki67
1 Pathologist
Not sure. Some glands at the edge that I would like to explore on deepers
1 Pathologist
ASC-H (one edge of the biopsy)
Favour tubo-endometrial metaplasia (vs endocervical glandular neoplasia/ AIS)
1 Pathologist
Focal discohesive atypical squamous cells
Order serials and deepers1 Pathologist
? Presence of focal high grade squamous dysplasia and tubal metaplasia of endocervical glands
1 Resident
Immature squamous metaplasia 1 Pathologist
Case 6
The answer is:Tubo-endometrioid metaplasia
Tubo-endometrioid metaplasia
Tubo-endometrioid metaplasia of the cervix is the type of metaplasia that is histologically similar to the tubal metaplasia that can develop in the endometrium in patients with unopposed estrogen
The glands are lined by a pseudostratified epithelium composed of columnar cells with a high N/C ratio
Many of the cells are ciliated or have secretory features with apical snouts
The glands lack an associated endometrial stroma Tubo-endometrioid metaplasia occurs commonly
after cervical conization
Tubo-endometrioid metaplasia
Because of the pseudostratification and high N/C ratio, these glands can be misinterpreted as AIS
Tubo-endometrioid or tubal metaplasia should not be misinterpreted as AIS because of the presence of bland nuclei and the absence of significant mitotic activity
Immunohistochemical panels of p16, Ki-67, CEA are used by some in difficult cases
Adenocarcinoma in situ