QA CONFERENCE Conf #1, May 23, 2012

1. QA CONFERENCEConf #1, May 23, 2012 By Dr. E. Ravinsky

2. CASE 1 • 54 year old female • Right breast core biopsy • Central calcs • R/O DCIS • Moderate probability • Magnification x 4

3. CASE 1 • Magnification x 20

4. CASE 1 • Magnification x 20

5. Case 1

6. CASE 1 • Magnification x 20

7. Case 1

8. CASE 1 • Immunohistochemistry CK5/6

9. CASE 1 • The answer is: • Atypical duct hyperplasia

10. Case 2 • 50 year old female • Right breast core biopsy • Calcs lower aspect • R/O DCIS • Magnification x 2

11. Case 2 • Magnification x 4

12. Case 1 • Magnification x 20

13. Case 2 • Magnification x 10

14. Case 2 • Magnification x 20

15. Case 2

16. Case 2 • The answer is: • Atypical duct hyperplasia

17. 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

18. Atypical Duct Hyperplasia • Quantitative features: • One duct with qualitative features of DCIS • Ducts with qualitative features of DCIS less than 2.0 mm across

19. 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

20. 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

21. 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 Atypical Duct Hyperplasia

22. Florid Duct Hyperplasia

23. Case 3 • 85 Year female • Unguided core biopsy right breast • Probable right breast cancer • Large central mass and clinically positive node • Magnification x 4

24. Case 3 • Magnification x 10

25. Case 3 • Magnification x 20

26. Case 3

27. Case 3 • Immunohistochemistry for CD45

28. Case 3 • The answer is: • Lymphoma breast

29. 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

30. 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

31. 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

32. Lymphoma Breast

33. Lymphoma Breast (signet-ring)

34. Lymphoma Breast

35. Lymphoma breast (angiocentric)

36. Solid papillary carcinoma

37. Solid papillary carcinoma

38. Case 4 • Biopsy vulva • 52 year old female • Labial lesion • R/O VIN • Magnification x 2

39. Case 4 • Magnification x 10

40. Case 4 • Magnification x 20

41. Case 4 • Magnification x 20

42. Case 4

43. 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

44. Case 4 • THE ANSWER IS: • Paget disease of vulva

45. Paget Disease of Vulva

46. Staining of Paget disease

47. Morphology of Paget disease

48. Immunohistochemical Staining

49. 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

50. Case 5 • Magnification x 10