Qa conference conf 1 may 23 2012
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QA CONFERENCE Conf #1, May 23, 2012. By Dr. E. Ravinsky. CASE 1. 54 year old female Right breast core biopsy Central calcs R/O DCIS Moderate probability Magnification x 4. CASE 1. Magnification x 20. CASE 1. Magnification x 20. Case 1. CASE 1. Magnification x 20. Case 1. CASE 1.

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QA CONFERENCE Conf #1, May 23, 2012

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QA CONFERENCEConf #1, May 23, 2012

By Dr. E. Ravinsky


CASE 1

  • 54 year old female

  • Right breast core biopsy

  • Central calcs

  • R/O DCIS

  • Moderate probability

  • Magnification x 4


CASE 1

  • Magnification x 20


CASE 1

  • Magnification x 20


Case 1


CASE 1

  • Magnification x 20


Case 1


CASE 1

  • Immunohistochemistry CK5/6


CASE 1

  • The answer is:

    • Atypical duct hyperplasia


Case 2

  • 50 year old female

  • Right breast core biopsy

  • Calcs lower aspect

  • R/O DCIS

  • Magnification x 2


Case 2

  • Magnification x 4


Case 1

  • Magnification x 20


Case 2

  • Magnification x 10


Case 2

  • Magnification x 20


Case 2


Case 2

  • The answer is:

    • Atypical duct hyperplasia


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


Atypical Duct Hyperplasia

  • Quantitative features:

    • One duct with qualitative features of DCIS

    • Ducts with qualitative features of DCIS less than 2.0 mm across


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


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


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


Florid Duct Hyperplasia


Case 3

  • 85 Year female

  • Unguided core biopsy right breast

  • Probable right breast cancer

  • Large central mass and clinically positive node

  • Magnification x 4


Case 3

  • Magnification x 10


Case 3

  • Magnification x 20


Case 3


Case 3

  • Immunohistochemistry for CD45


Case 3

  • The answer is:

    • Lymphoma breast


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


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


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


Lymphoma Breast


Lymphoma Breast (signet-ring)


Lymphoma Breast


Lymphoma breast (angiocentric)


Solid papillary carcinoma


Solid papillary carcinoma


Case 4

  • Biopsy vulva

  • 52 year old female

  • Labial lesion

  • R/O VIN

  • Magnification x 2


Case 4

  • Magnification x 10


Case 4

  • Magnification x 20


Case 4

  • Magnification x 20


Case 4


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


Case 4

  • THE ANSWER IS:

    • Paget disease of vulva


Paget Disease of Vulva


Staining of Paget disease


Morphology of Paget disease


Immunohistochemical Staining


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


Case 5

  • Magnification x 10


Case 5

  • Magnification x 20


Case 5


Case 5

  • The answer is

    • Endometriosis of cervix


Endometriosis of cervix

  • Endometriosis of cervix is not uncommon

  • It is usually confined to the superficial third of the cervical wall

  • They appear as small blue or red nodules on the cervix

  • Histologically, the glands and stroma resemble proliferative endometrium

  • The mechanism responsible for the development of endometriosis is unknown, but it frequently develops following cervical trauma

  • Cervical endometriosis occurs in 5-43% of patients who have had cautery, cone biopsy or LEEP excisions


Endometriosis of cervix

  • Endometriosis can be mistaken for AIS

  • The cells of normal proliferating endometrium are very active

  • They are pseudostratified. They have large oval nuclei with numerous nucleoli

  • Numerous mitoses are identified


Endometriosis of cervix

  • How to identify endometriosis of cervix:

    • The glandular cells of endometriosis have an endometriotic appearance with a moderate amount of basophilic cytoplasm and regular oval nuclei

    • Endometriosis can be recognized by the presence of endometrial-type stroma, but the pathologist must be aware of the possibility or s/he might concentrate on the glands and not notice it

    • In some cases, there may be abundant hemorrhage and the endometrial-type stroma might not be obvious

    • The presence of small arterioles like the spiral arterioles can help identify the presence of endometrial-type stroma

    • CD10 can confirm the endometrioid nature of the stroma


Case 6

  • 37 year old female with 2 ASCUS diagnoses on cervico-vaginal smear

  • Biopsy cervix taken at colposcopy

  • Colposcopic impression “?CIN1”

  • Magnification x 4


Case 6

  • Magnification x 10


Case 6

  • Magnification x 20


Case 6

  • Mangification x 20


Case 6

  • Magnification x 40


Case 6


Case 6

  • The answer is:

    • Tubo-endometrioid metaplasia


Tubo-endometrioid metaplasia

  • Tubo-endometrioid metaplasia of the cervix is the type of metaplasia that is histologically similar to the tubal metaplasia that can develop in the endometrium in patients with unopposed estrogen

  • The glands are lined by a pseudostratified epithelium composed of columnar cells with a high N/C ratio

  • Many of the cells are ciliated or have secretory features with apical snouts

  • The glands lack an associated endometrial stroma

  • Tubo-endometrioid metaplasia occurs commonly after cervical conization


Tubo-endometrioid metaplasia

  • Because of the pseudostratification and high N/C ratio, these glands can be misinterpreted as AIS

  • Tubo-endometrioid or tubal metaplasia should not be misinterpreted as AIS because of the presence of bland nuclei and the absence of significant mitotic activity

  • Immunohistochemical panels of p16, Ki-67, CEA are used by some in difficult cases


Adenocarcinoma in situ


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