community hospital experiences with head and neck surgeons

1. Community Hospital Experiences with Head and Neck Surgeons Randall K McGivney D.O. FCAP MBA Chair, Department of Pathology and Laboratory Sciences MacNeal and Weiss Hospitals Medical Director, Genesis Clinical Laboratory

2. Case:1 29 year old female with left neck mass The endocrinologist submits the following FNA with the history noted above Remainder of the exam and history are negative

5. HBME-1

6. Cytokeratin 19

7. Case 2: 33 year old female with right neck mass - FNA

9. FNA Diagnosis Rule out Medullary Carcinoma Elevated calcitonin and chromogranin A Total thyroidectomy Cervical lymphadenectomy Solitary Mass Sporadic: 80%, Familial: 20% MEN 2A, 2B syndromes familial medullary thyroid carcinoma syndrome, von Hippel-Lindau disease or neurofibromatosis; usually bilateral, multicentric and younger patients (mean age 35) MEN 2A: due to germ line mutations in RET proto-oncogene; fewer distant metastases

15. Follow Up Patient does well and serum Calcitonin drops 6 months later she presents to the ED with intractable diarrhea and is admitted with hyponatremia and hypokalemia While under going treatment she suddenly seizes, arrests and dies and presents at autopsy

16. Pancreas Mass

17. Liver

18. 10x microscopic of the Liver

19. Cause of Death Metastatic VIPoma of the Pancreas to Liver Resulting in profuse diarrhea Resulting in marked hypokalemia (low serum potassium) Resulting in a ventricular arrhythmia and death

21. Case 3: 50 year male Presents with swelling at the angle of the jaw FNA to rule out metastatic carcinoma or lymphoma

24. FNA � Rule Out Acinic Cell Carcinoma of the Parotid Gland

27. Acinic Cell Carcinoma with Clear Cell Features 80-90% recur if incompletely excised 5 year survival 90%, 20 year survival 60% Less aggressive in minor salivary glands Cytokeratin +, Myoepithelial markers (CD10, S100 and Actins), granules are PAS+ diastase resistant

28. Case 4: 35 year old man with 3 cm submandibular mass

30. FNA � Rule Out Adenoid Cystic Carcinoma

31. Radical Surgery Tumor is solid, poorly encapsulated and infiltrative Histology Cribriform, solid or tubular pattern (cylindromas of skin) small bland myoepithelial cells with scant cytoplasm and dark compact angular nuclei surround pseudo glandular spaces with PAS+ excess basement membrane material and mucin; Perineurial invasion

32. Grading Adenoid Cystic Carcinoma Grade 1 : Tubular and cribriform Grade 2: 30% to ~70% solid Grade 3: Almost all solid

33. Prognosis for Adenoid Cystic Carcinoma Slow growing but aggressive; 50% metastasize, often silently to lung or bone; recurrences are frequent and often late 5 year survival is 60%, 10 year is 30%, 15 year is 15% Higher recurrence rates for solid (100%) vs. cribriform (89%) vs. tubular (59%) patterns 15 year survival rates by pattern are solid (5%), cribriform (26%), tubular (39%)

34. Case 5: 65 year old female 3 cm Parotid Mass

35. FNA - Favor Adenoid Cystic Carcinoma Low grade with Epithelial and Myoepithelial components Myoepithelial features with clear cytoplasm

36. Ordered Cytokeratin, PAS, S100, MSA, Calponin and p63 Ducts with an outer rim of myoepithelial cells and inner, dark ductal cells with scant eosinophilic cytoplasm and round, bland nuclei

37. Cytokeratin AE1/AE3

38. S100 Epithelial � Myoepithelial Carcinoma

39. Case 6: 19 year old Chinese Female Nasal Polyp Biopsy to rule out lymphoma

41. Cytokeratin AE1/AE3

43. Nonkeratinizing carcinoma-undifferentiated (WHO Type 3) Very rare in US, common in Taiwan and China Lymphoepithelioma 5 year survival after radiation therapy alone is based on stage--confined to nasopharynx (stage I): 50-60%; cervical node involvement (stage II): 20-30%; invasion of surrounding structures (stage III): 5-30% Metastasize to regional lymph nodes

44. Histologic Patterns Regaud pattern: neoplastic cells form well defined cohesive nests and cords separated by inflammation Schminke pattern: inflammatory cells permeate cells nests causing isolation of carcinoma cells within lymphoid background, resembling lymphoma; tumor cells have thin chromatin rims and lack lacunae CK 5/6, CK8, CK13, CK19), EBER1 by in situ hybridization

45. Epithelial Myoepithelial Carcinoma Rare (less than 0.5% of salivary gland tumors); 80% arise in parotid gland Low grade malignancies with frequent local recurrences Rare regional nodal metastases and distant metastases to lung and kidney Cases with cytologic atypia and infiltrative pattern see metastases in 47% cases and 30% die of disease

46. Case 7: 37 year Female Nasal Biopsy Nasal Mass extending into the sinuses Pulmonary Nodules Increased Creatinine 2.1 Diagnostic for Wegener�s: granulomatous inflammation, necrosis and vasculitis, in addition to clinical involvement of lung or kidney; OR two of three microscopic features and lung and kidney involvement

47. Histologic Findings Leukocytoclastic vasculitis of arterioles, small arteries and veins with geographic necrosis surrounded by palisading histiocytes, variable poorly formed granulomas with minimal lymphocytes; variable giant cells; granulomas and giant cells are distant from vessels or adjacent/within vessel wall; also epithelial ulcers; vessel may be obliterated by inflammatory cells and thrombus and be difficult to identify without elastic stain; all stages of vasculitis are present (acute: neutrophils with fibrinoid necrosis; chronic/healed: narrowed or obliterated lumina with concentric rims of perivascular collagen); usually no significant lymphoid infiltrate

50. Wegener�s but c-ANCA and p-ANCA Negative

51. Bronchial Wash � Diff Quick

52. PAS on Bronchial Biopsy � Aspergillus {One or Both}