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SPUC 1/28/08

SPUC 1/28/08. Case 1: Anaplastic carcinoma- thyroid. 10% of thyroid malignancies Typically older women, rapidly enlarging mass, with or without dyspnea May arise from lower grade carcinoma, (commonly follicular carcinoma) Gross: Solid, +/- hemorrhage and necrosis, +/- extrathyroidal spread

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SPUC 1/28/08

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  1. SPUC 1/28/08

  2. Case 1: Anaplastic carcinoma- thyroid • 10% of thyroid malignancies • Typically older women, rapidly enlarging mass, with or without dyspnea • May arise from lower grade carcinoma, (commonly follicular carcinoma) • Gross: Solid, +/- hemorrhage and necrosis, +/- extrathyroidal spread • Micro: high grade, undifferentiated or spindle cells, +/- osteoclastic giant cells

  3. Case 1: Anaplastic carcinoma- thyroid • DDX: Sarcoma, melanoma, metastatic carcinoma, lymphoma • IHC: CK pos, thyroglobulin/TTF-1 neg, S-100 neg, other routine markers negative • EM: shows thyroid epithelial differentiation • Prognosis: Poor • T4 tumor by definition • T4a: No extrathyroidal extension/resectable • T4b: Extrathyroidal/unresectable

  4. Case 2: MPNST • Often associated with nerve (implies schwannian origin) • Mean age: 30-40 (or younger for epithelioid type) • May occur almost anywhere • Micro: monomorphic serpentine cells, palisading, large gaping vascular spaces, perivascular plump tumor cells, geographic necrosis with tumor pallisading at the edges (resembles glioblastoma multiforme) • May look like a low grade neurofibroma

  5. Case 2: MPNST • Count mitoses: greater than 1 per 20 HPF indicates potential malignancy • DDX: schwannoma/neurofibroma, carcinoma, melanoma, sarcoma (esp GIST, LMS in this site) • IHC: S-100 is never diffuse and usually not strong. WT1 (100%, n=2), Vimentin (88%), CD99 (88%). • Some may show glandular (CK, EMA) or metaplastic differentiation (muscle, bone) • Triton tumor: MPNST with skeletal muscle • +/- melanotic, esp if arising from spinal nerve roots

  6. Case 3: Serous borderline tumor (SBT) • AKA: Atypical proliferating serous tumor • Mean age: 45; 50% are bilateral • Need staging (lymph nodes, peritoneum) • May be disseminated as implants, which can be invasive or non-invasive • Important to rule out invasion of stroma at primary site • Microinvasion: foci should not exceed than 10 mm2

  7. Case 3: Serous borderline tumor (SBT) • Papillary (typical) and micropapillary types • Typical: Hierarchical and complex branching papillary structures, with epithelial hyperplasia (stratification) • Micropapillary: Non-hierarchical (medusa head appearance) • Mild to moderate cytologic atypia • Stage III tumors (with peritoneal implants) have 5 yr survival at 55-75%

  8. Case 3: Benign serous tumor(cystadenoma, adenofribroma) • Most common serous tumor of ovary (16%) • Simple epithelium with hyperplasia that resembles fallopian tube epithelium • Mild atypia at most • Sometimes show a flat cyst lining • Borderline or benign serous tumors very rarely transform to serous carcinoma and do not have TP53 mutations

  9. Case 4: Invasive adenocarcinoma of pancreas • Most common type: Ductal carcinoma (85%); 90% have point mutations at codon 12 of Kras, a signal transducer for tyrosine kinase • Risk factors: Smoking, alcohol, obesity, beta-naphthylamine or benzidine exposure, familial relapsing pancreatitis, older age • Uncertain risk factors: chronic pancreatitis, diabetes (may be secondary to carcinoma), male (M/F = 1.6:1)

  10. Case 4: Invasive adenocarcinoma of pancreas (with features of IPMN) DDX: Colloid (mucinous noncystic) carcinoma, IPMN with carcinoma, mucinous cystic neoplasm (with ovarian stroma), metastatic • Invasive tumors containing foci of IPMN have better behavior than usual ductal type

  11. Case 4: Invasive adenocarcinoma of pancreas (with features of IPMN) • IPMN: • 30% associated with invasive carcinoma, which is often colloid carcinoma • resect entire tumor, sample extensively (> 50 blocks) to rule out invasion or atypia (often multifocal) • Intestinal, pancreaticobiliary, oncocytic types • Pathognomic: Bulging out of ampullary papilla • Communicates with duct system

  12. Case 5: Goblet cell carcinoid of colon • Most common in appendix • DDx: signet-ring carcinoma (metastatic or primary), classic carcinoid tumor (no goblet cell differentiation), mucinous adenocarcinomas

  13. Case 5: Goblet cell carcinoid of colon • Also called mucinous carcinoid, adenocarcinoid, microglandular goblet cell carcinoma • Positive stains: mucin, CEA, cytokeratin, lysozyme, chromogranin A, serotonin, synaptophysin • Tumor is often aggressive and behaves more like a signet ring cell adenocarcinoma

  14. Case 5: Goblet cell carcinoid of colon • Classical carcinoids of appendix: If greater than 2 cm, 30% chance of mets • Classical carcinoids of colon, usually rectum: Increased chance of mets if greater than 2 cm

  15. Case 6: Capsular nevus Incidence in axillary nodes is 7% per patient and 0.5% per node in one study (AJCP 1994;102:102) • Presence in sentinel nodes in melanoma patients is associated with cutaneous nevi (AJCP 2004;121:58) and congenital cutaneous nevi (Am J Dermatopathol 2002;24:1) • May represent benign metastases from intradermal nevus in area of lymphatic drainage (AJCP 1985;84:220)

  16. Case 6: Capsular nevus • Micro: single cells, linear arrangements or aggregates of B9 appearing nevus cells, usually within fibrous capsule and trabeculae, but also within nodal parenchyma • Other benign inclusions to look out for: • Mullerian inclusions (eg endosalpingiosis) • TDLU inclusions (axillary); with range of usual changes • Mesothelial cells • Salivary gland inclusions • Thymus, thyroid, squamous inclusions

  17. Case 7: Borderline mucinous tumor (BMT) of ovary • 10% bilateral • Pure borderline tumors and borderline tumors with intraepithelial carcinoma are almost always Stage 1 and clinically benign -- must sample tumor extensively to rule out invasion • High stage borderline tumors with abdominal cavity mucin probably represent metastases rather than primary borderline tumors - must examine appendix to correctly interpret

  18. Case 7: Borderline mucinous tumor (BMT) of ovary • Noninvasive with intraglandular or intracystic epithelial proliferations (architectural complexity) • Endocervical (mullerian) or intestinal types (more common) • May show slight cytologic atypia with mild stratification to frank intraepithelial carcinoma with 4+ layers or cribriform or stroma-free papillary growth • Invasion = at least 10 mm2 of confluent glands/complex papillary areas, or frankly infiltrative glands/nests exceeding 10 mm2

  19. Case 7: Borderline mucinous tumor (BMT) of ovary • Endocervical type may be associated with noninvasive or invasive implants • Microinvasive mucinous adenocarcinoma: • Same prognosis as mucinous borderline tumor • Small stromal foci (up to 2 mm) of single cells / small clusters of cells, occasionally cribriform

  20. Case 8: Malignant mixed mullerian tumor of uterus with metastatic disease DDX: Sarcoma (LMS), lymphoma, undifferentiated carcinoma, melanoma

  21. Case 9: Large cell neuroendocrine carcinoma of lung • DDX: • Metastatic poorly or undifferentiated CA • Large cell carcinoma (NEW WHO) • Undifferentiated type • Large cell neuroendocrine carcinoma • NSCLC with neuroendocrine differentiation • Carcinoma with pleomorphic, sarcomatoid, or sarcomatous elements

  22. Case 10: Mixed serous and clear cell carcinoma of ovary (50% each)

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