SPUC 12808

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SPUC 1/28/08
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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

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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

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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

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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, n2), 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

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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

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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

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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

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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 1.61)

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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

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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 (gt 50
  blocks) to rule out invasion or atypia (often
  multifocal)
• Intestinal, pancreaticobiliary, oncocytic types
• Pathognomic Bulging out of ampullary papilla
• Communicates with duct system

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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

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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

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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

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Case 6 Capsular nevus

• Incidence in axillary nodes is 7 per patient and
  0.5 per node in one study (AJCP 1994102102)
• Presence in sentinel nodes in melanoma patients
  is associated with cutaneous nevi (AJCP
  200412158) and congenital cutaneous nevi (Am J
  Dermatopathol 2002241)
• May represent benign metastases from intradermal
  nevus in area of lymphatic drainage (AJCP
  198584220)

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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

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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

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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

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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

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Case 8 Malignant mixed mullerian tumor of
uterus with metastatic disease

• DDX
• Sarcoma (LMS), lymphoma, undifferentiated
  carcinoma, melanoma

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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

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Case 10 Mixed serous and clear cell carcinoma
of ovary (50 each)