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SURGICAL PATHOLOGY UNKNOWN CONFERENCE 6-18-07

SURGICAL PATHOLOGY UNKNOWN CONFERENCE 6-18-07. Samia Nawaz MD. Case 1. 70 year old male with gastric polyp. Case 1: Carcinoid tumor. Carcinoid tumor 1.3 cm size Neg surgical margins. Carcinoid tumor. Benign Or Malignant. All carcinoids are potentially malignant.

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SURGICAL PATHOLOGY UNKNOWN CONFERENCE 6-18-07

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  1. SURGICAL PATHOLOGY UNKNOWN CONFERENCE6-18-07 Samia Nawaz MD

  2. Case 1 70 year old male with gastric polyp

  3. Case 1: Carcinoid tumor • Carcinoid tumor • 1.3 cm size • Neg surgical margins

  4. Carcinoid tumor Benign Or Malignant

  5. All carcinoids are potentially malignant • Increased risk of malignant if: • Size > 2cm • Invasion of muscle • Mitoses> 2/HPF

  6. Carcinoid tumor • Incidental • Bowel obstruction • Mets • Ischemic bowel • Carcinoid syndrome

  7. Gastrointestinal Carcinoid Tumors • Esophageal - Exceptionally rare • Gastric - 0.5% • Small bowel - 25-35%Duodenum - 2% Jejunum - 7% Ileum - 91% Multiple sites - 15-35% • Appendix - 30-45% (most benign) • Colon - 5% (most in ascending colon) • Rectum - 10-15% • Pancreas - Rare • Liver - Primary, exceptionally rare • Biliary tract – Rare

  8. Gastric Carcinoids Peculiar features

  9. Gastric Carcinoids 1. Associated with pernicious anemia Multiple, small, occasional mets, fatal 2. Part of MEN syndrome: low grade malignant potential 3. Sporadic carcinoid: single, 50% spread in malignant fashion

  10. Duodenal carcinoids Peculiar features

  11. Deudonal carcinoids • Periampullary region • Some are somatostatinoma ( psammoma bodies) • Gastrinomas: Z E syndrome • 20% metastasize

  12. Case 2 50 year old male with ileocecal mass

  13. Case 2: Malignant Carcinoid • Malignant Carcinoid arising in ileocecal/appendiceal orifice • Muscle invasion, and into the serosa • Multiple peritoneal implants • LVI +, perineural invasion + • Mets in 8/10 LNs with extracapsular extention

  14. Carcinoid tumor

  15. AdenocarcinoidGoblet cell carcinoid • Derived from pluripotent cell • Histologic features of adenoca & carcinoid • Positive for: chromogranin, synaptophysin, NSE, CK7,CK20, CEA

  16. Differential DX Adenocarcinoma

  17. Differential Dx • Surface mucosal epith not neoplastic in malignant carcinoid • Carcinoid: location intramural • Stains

  18. Case 3 67 year old male with left parotid mass

  19. Case 3 • High grade muco-epidermoid ca • 3.4cm in size • Peri-neural invasion present • LVI not present • Surgical margins positive • Lymph node dissection: 0/19 • Mucin stain: focally +

  20. Mucoepidermoid ca • Most common malignant salivary gl tumor • epidermoid and mucous secreting cells • 3 distinct cell types: epidermoid, mucus producing cells, intermediate (basal cells) • Low grade: slow growth, painless, cystic rich in mucous producing cells • High grade: rapid growth, painful, solid rich in epidermoid cells, Perineural inv +

  21. Mucoepidermoid Ca • Pediatric population: usually low grade • Metastases: both mucous and epidermoid cells • Extravasation of mucous: inflammatory rxn

  22. Differential Dx • Cystadenoma • Acinic cell Ca • SCC: primary or metastatic • Adenosquamous Ca • Clear cell Ca • Metastatic renal cell Ca

  23. Case 4 65 year old male with right kidney mass

  24. Case 4:Right, partial nephrectomy • Papillary renal cell Ca chromophil type • 3.5 cm in size • Fuhrman grade: 2/4 • LVI not present • All surgical margins negative • AJCC stage I ( T1a, Nx, Mx)

  25. Case 4: Left Renal mass • Papillary RCC, chromophil type • 4 cm in greatest dimension • Furhman grade 2 of 4. • LVI is not identified. • Tumor extends through the renal capsule into the perinephric fat • Surgical margins free of involvement • AJCC pTNM Stage III (T3a Nx Mx).

  26. Renal epithelial tumors : • Clear cell Ca 75 to 85 % • Chromophilic (papillary) 10 to 15 % • Chromophobic (5 to 10 % • Oncocytic (uncommon) • Collecting duct (Bellini's duct) (rare)

  27. Papillary RCC: Gross • Bilateral, multifocal • Encapsulated • Hemorrhage, necrosis • calcifications

  28. Papillary RCC: Micro • True papillae with fibrovascular core • lined by neoplastc epithelial cells • expanded by foamy macrophages • Focal sarcomatoid areas ( aggressive) • Hyperchromatic stratified nuclei, (aggressive)

  29. Papillary RCC: genetics • Both clear cell cancers, and chromophilic tumors originate from the proximal tubule, but they are morphologically and genetically distinct malignancies. • Among 29 malignant papillary RCCs, - trisomy 16 was present in 20 tumors - trisomy 12 in 8 cases - trisomy 20 in 8 cases • No tumor had an abnormality in 3p, which is the typical finding in clear cell carcinomas.

  30. Papillary RCC: Diff Dx • Clear cell Ca ( CK 7 – in Clear cell Ca, but focally + in Papillary RCC) • Collecting duct Ca ( location in medulla, high grade)

  31. Case 5 82 year old male with bladder cancer

  32. Case 5: Collision tumor • Transitional cell CA of bladder - Sarcomatoid and squamous areas - Extending into extravsical soft tissue • AdenoCa of prostate: - Gleason grade 5+4( sum=9) - Extracapsular invasion - perineural invasion - Met to pelvic lymph node

  33. Collision tumor • two histologically distinct neoplasms simultaneously arising adjacent to each other in the same organ. • sharp, delineated interface without evidence of interdigitating components. • skin, stomach, esophagus, liver, lung, uterus, cervix, etc. • collision of non-Hodgkin's lymphoma and Kaposi's sarcoma in immunosuppressed HIV-positive individuals.

  34. International Journal of Surgical PathologyVol. 15, No. 2, 213-218 (2007) Poorly Differentiated Adenocarcinoma of Prostate of the Bladder: A Diagnostic Dilemma With Immunohistochemical Evaluation of 2 Cases Miguel Martínez-Rodríguez, MD Prostate ca: positive for PSA and alpha methyl racemase Urothelial ca: positive for CK7, CK20, Ag 34ßE12, and p53 in the urothelial carcinoma.

  35. Case 6 71 year old male with pleural effusion

  36. Case 6: stains • Positive for: Cytokeratin • Nagative for: calretinin desmin S100 MSA

  37. Case 6: Giant cell Ca of lung • Entire right lung and LUL • Direct extention tpo pericardium • Metastases: hilar LN, carinal LN, para aortic LN liver, spleen, b marrow, pituitary, both adrenals

  38. Lung: Malignant Epithelial tumors 1.Squamous cell ca7 Carcinoid tumor 2. Small cell ca 8 Ca of saliv gl type 3. Adenoca 9 Unclassified ca 4. Large cell ca 5 Adenosquamous ca 6 Ca with pleomorphic,sarcomatoid elements 6.1 Pleomorphic ca:A Ca with spindle/ giant cells B Pleomorphic ca, C Spindle cell ca, D.Giant cell ca • 6.2 Carcinosarcoma • 6.3 Blastoma (pulmonary blastoma) • 6.4 Others

  39. Giant cell ca of lung • Composed of at least 40% GC • GC size >40u • Discohesive cells • CK +, CEA + • PMNs, emperiopolesis • Frequent mets to GI system • Clinical: fever. r/o infection • Poor prognosis

  40. GC ca of lung: Diff Dx • Sarcoma (MFH inflammatory): CK, EMA • Adenoca: mucin, • Lymphoma: LCA • Chorioca: villous pattern, HCG • Metastatic giant cell ca

  41. Case 7 39 year old male with purulent left thigh lesion since 6 months

  42. Case 7:stains • Positive: HMB 45, desmin, SMA, CD10 and tyrosinase • Negative: keratin, CK5/6, EMA, S100, CD34, CD177, Myo D,

  43. Case 7 • High grade sarcoma with myomelanocytic differentiation • Well delineated w fibrous pseudo capsule • Surg margin narrowly clear • Spindled/epitheliod highly pleomorphic cells • Features s/o malignant PEComa

  44. PEComa • Perivascular Epithelial Cell • No known normal tissue counterpart • Coexpression of muscle & melanocytic markers ( IHC, EM) • Benign, borderline, malignant

  45. History of PEComa • 1991: Pea et al: case of pulmonary clear cell sugar tumor: HMB45 + • Two reports:Bonetti et al & Chan et al: smooth msl like cells in (LAM) lymphangiomyomatosis: HMB45 + 1994: Angimyolipoma & CCST 1996: PEComa in : rectum, vulva, breast, uterus, skull base, saliv gl, skin, abd wall

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