Reporting Categories For Breast Fine Needle Aspirates And Wide Bore Needle Core Biopsies
FNAC is highly efficient and accurate at diagnosing a wide range of breast disease when interpreted in conjunction with the patient's age, clinical history, clinical features of the lesion and its radiological appearances. Two basic patterns are encountered 1. Benign a biphasic pattern of cohesive breast epithelium and background bare nuclei low to moderate cellularity (except fibroadenoma, which is of high cellularity) 2. Malignant dyscohesive clusters and singles of variably atypical...
Gynaecological Cancer
Iatrogenic lesions of the female genital tract. Curr Diagn Pathol 2003 9 105-113. Clement PB, Young RH. Atlas of Gynecologic Pathology. Saunders. Philadelphia 2000. Fox H, Wells M (eds). Haines and Taylor's obstetrical and gynaecological pathology, 5th edn. Churchill Livingstone Elsevier. New York 2003. Lowe DG, Buckley CH, Fox H. Advances in gynaecological pathology. In Anthony PP, MacSween RNM (eds). Recent advances in histopathology 17. Churchill Livingstone. Edinburgh...
Extent Of Local Tumour Spread
Lymphocytic reaction prominent sparse. Distance to the proximal bronchial limit (mm). Distance to the mediastinal limit (mm). Distance to the pleura (mm). visceral pleural invasion is recognized by direct perforation of the mesothelium and also infiltration of the inner elastin layer in the sub-mesothelial plane. Note that the pleura can be distorted without actual true invasion and use of an elastin stain is helpful. Distance to the pericardium (mm). Mucosa,...
Lymph Nodes
Site number size number involved limit node extracapsular spread. Regional nodes pelvic nodes below the bifurcation of the common iliac arteries. pN0 no regional lymph node metastasis pN1 metastasis in regional lymph node(s). Lymph node metastases are present in up to 10-30 of radical prostatectomy specimens relating to tumour stage, volume, differentiation and serum PSA levels. Some patients with high-risk disease defined by serum PSA level and biopsy tumour grade may have frozen section...
Ovary
Ovarian epithelial tumours common problems in diagnosis. Curr Diagn Pathol 2004 10 473-499. Bell KA, Smith Sehdev AE, Kurman RJ. Refined diagnostic criteria for implants associated with ovarian atypical proliferative serous tumours (borderline) and micropapillary serous carcinomas. Am J Surg Pathol 2001 25 419-432. Eichorn JH, Bell DA, Young RH, Scully RE. Ovarian serous borderline tumours with micropapillary and cribriform patterns. A study of 40 cases and comparison with 44...
Other Malignancy
usually secondary to systemic nodal disease and present in up to 50 of cases, and potentially bilateral. If established as a primary lymphoma it is usually large B cell in type. Diffuse tumour cell permeation or tumour masses lymphoma is occasionally associated with renal cell carcinoma post-transplant lymphoproliferative disorder. Leiomyosarcoma, liposarcoma, malignant fibrous histiocytoma, rhabdomyosarcoma all rare and important to exclude more common diagnoses, i.e. sar-comatoid renal cell...
Other Pathology
HPV human papilloma virus anogenital field change of viral infection, intraepithelial neoplasia and carcinoma. CIN cervical intraepithelial neoplasia. SIL squamous intraepithelial lesion (Bethesda system). AIS EGD CGIN adenocarcinoma in-situ and lesser changes of endocervical glandular dysplasia (cervical glandular intraepithelial neoplasia) low-grade high-grade EGD CGIN. VAIN vaginal intraepithelial neoplasia VIN vulval intraepithelial neoplasia. AIN anal intraepithelial neoplasia. Bowenoid...
Germ cell
Common tissues are skin and appendage structures, muscle, fat, ganglia, glial tissue, respiratory, gastrointestinal and pancreatic glandular tissue, retinal elements, cartilage and bone. immature solid with histologically identifiable immature tissues, especially cartilage, neuroepithelium, striated muscle, endodermal glands and immature cellular mesenchyme. grade 1 mostly mature tissue, loose mesenchyme, immature cartilage, focal (< 1 low-power field slide)...
Others
Mucinous (colloid) adenocarcinoma in anal fistula which may be associated with Crohn's disease or hindgut duplication. Anal gland adenocarcinoma rare. In contrast to anorectal adenocarci-noma lacks O-acetylsialomucin (PAS negative post PB-KOH saponification). Late diagnosis, poor prognosis. Extra-mammary Paget's disease in 20 an underlying adnexal or rectal adenocarcinoma is found. The majority remain confined to the surface epithelium. Neuroendocrine carcinoma carcinoid small cell large cell...
Lymphovascular Invasion
Invasion into the lamina propria may result in prominent retraction artefact spaces around tumour cells and nests mimicking lymphovascu-lar invasion. This phenomenon is particularly prominent in micropapil-lary carcinoma. For true vascular involvement identify an endothelial lining with adherent tumour and red blood cells. Endothelial markers (CD31, CD34) may be of use. Vascular invasion is associated with an increased rate of recurrence.
Carcinoid tumour
positive. typically insular pattern of uniform cells in a dense fibrous stroma with vascular thickening. 20 have carcinoid syndrome implying liver metastases facial flushing asthma thickening of cardiac valves due to release of the vasoac-tive peptides (e.g. serotonin) into the systemic circulation. low-grade malignancy any functioning well-differentiated tumour any tumour with angioinvasion non-functioning tumour > 2 cm or with invasion beyond the submucosa. high-grade malignancy tumour...
Liver Carcinoma
fine needle aspirate core biopsy wedge excision segmentectomy partial hepatectomy R L lobectomy. Hepatic resection in malignant disease is potentially considered for primary liver tumour involving a single lobe with no invasion of portal vein or inferior vena cava and no significant background cirrhosis. isolated metastases (e.g. carcinoid, colorectal carcinoma) localized to a single lobe with no metastatic spread elsewhere and adequate excision of the primary lesion. Depending on the...
Clinical Stage
Modified Royal Marsden Staging System I tumour confined to the testis II nodes involved below the diaphragm III nodes involved above the diaphragm supraclavicular or mediastinal IV extranodal metastases lung or brain. Up to 30 of patients with seminoma have metastases at the time of diagnosis, 50-60 with embryonal carcinoma and the majority with choriocarcinoma. Clinical staging is based on the determination of the anatomical extent of disease and the assessment of postorchidectomy serum...
Specimen
fine needle aspirate needle core biopsy localization biopsy open biopsy segmental excision partial mastectomy mastectomy. Optimal fixation is important in assessing tumour type, grade, lymphovascu-lar invasion and hormone receptor expression. axillary nodes sentinel biopsy sampling clearance. symptomatic breast cancer usually presents with a palpable lump, skin tethering, nipple rash (Paget's disease) retraction or discharge. Asymptomatic in-situ or invasive lesions are detected at two-view...
Differentiation
80-85 are well to moderately differentiated. Grade I II III for endometrioid adenocarcinoma. The glandular component of endometrioid adenocarcinomas is graded I < 5 , II 6-50 , and III > 50 non-squamous, non-morular solid growth pattern. Nuclear grading can also raise the architectural grade, e.g. II III grade 1 (oval nuclei, even chromatin, inconspicuous nucleolus, few mitoses) and grade 3 (irregular, rounded nuclei, prominent nucleoli, frequent mitoses). Grade 2 nuclear grade is...
Excision Margins
Distances (mm) to the nearest painted deep and peripheral excision margins either of quadrant blocks if specimen size allows or serial slices (toast racked) of the vertical and radial disease phases and any in-situ change. Minimum recommended margins of clearance vary according to the tumour depth of invasion Adequate treatment is based on successful complete primary excision or, if there is initial margin involvement, secondary re-excision. This is supplemented by regional node dissection and...
Tumour
ovarian (cystic, cortical, medullary, hilar or serosal) paratubal broad ligament. serosal tumour is associated with a worse prognosis than an equivalent cortical or intracystic lesion. Medullary, hilar or paraovarian tumour nodules may indicate a metastatic deposit rather than a primary lesion. unilateral bilateral (30-40 of serous epithelial lesions). length x width x depth (cm) or maximum dimension (cm). Appearance Capsule intact deficient, smooth rough. Cut surface warty growths nodules...
Leukaemia
5-10 of leukaemia cases sometimes as a first manifestation of disease but more often secondary to widespread systemic or recurrent disease. children acute lymphoblastic leukaemia (ALL) (CD79a, CD10 (CALLA) positive tdt, Ki-67 > 90 ). adults chronic lymphocytic leukaemia (CLL) (CD5, CD23) or CML (CD68 chloroactetate esterase myeloperoxidase). Also multiple myeloma (CD79a, CD138, K, light chain restriction, Bence-Jones proteinuria, monoclonal gammopathy, lytic skull lesions).
Oestrogenprogesterone receptor expression
Positive in 70-80 of ductal (usually grade 1 2) cancers and 70-90 of infiltrating lobular carcinomas. Most postmenopausal patients receive the anti-oestrogen tamoxifen but positive oestrogen receptor (ER) status in premenopausal patients is important so that consideration can be given to hormonal treatment. Progesterone receptor expression is a prognostic marker and may also indicate hormone responsiveness. tissue for staining choose block (formalin fixed) with tumour and normal breast elements...
Sex cordstromal
well moderate poor differentiation but weak correlation with prognosis and grading is more dependent on the specific tumour type. Functional e.g. oestrogenic drive to endometrium in thecoma (25 of cases), granulosa cell tumour virilization in Sertoli-Leydig tumour. Prognosis relates to size (< or > 5 cm), an intact or deficient capsule, bulk of extraovarian disease, atypia, mitoses (per 10hpfs), necrosis and bilaterality. Recurrence (30 ) tends to be local. It may be extrapelvic and after...
Associations
Thirty to forty-five percent of thymoma patients have myasthenia gravis muscular fatigability of the proximal limbs and head and neck, acetylcholine receptor antibody. Other paraneoplastic syndromes relate to the mediastinal cancer type, e.g. small cell lung carcinoma with ACTH or inappropriate ADH secretion. Thymic carcinoid tumour is associated with carcinoid tumour at other sites, e.g. bronchus, ileum and MEN I syndrome. Typically ribbons, rosettes, and balls of cells with central necrosis...
Endometrium
EIN (endometrial intraepithelial neoplasia) is an umbrella term encompassing and highlighting the diagnostic difficulties there are in distinguishing between entities on the overlap spectrum of complex endometrial hyperplasia with atypia and intra-endometrial adenocarcinoma (pT1a). Progression along the spectrum is characterized by increased glandular crowding and cytological atypia with reduction in intervening stroma. An important differential diagnosis is a benign mimic with focal glandular...
Histological Type And Differentiationgrade
Therapeutic and prognostic distinction is made between Hodgkin's and non-Hodgkin's malignant lymphoma, with a significant proportion of the former being reclassified as variants of the latter on the basis of improved immunophenotyping. Within classical Hodgkin's lymphoma there is a differentiation spectrum from nodular sclerosis through mixed cellular-ity to lymphocyte depleted, with the former divided into two subtypes that are of prognostic significance in limited stage disease. In...
Histological Type
Crucial therapeutic distinction is made between small cell carcinoma and non-small cell (squamous adenocarcinoma large cell) carcinoma. 40-50 of cases. Requires nuclear stratification, intercellular bridges, keratinization. spindle cell (see carcinosarcoma) cytokeratin positive vimentin positive. basaloid poor prognosis, nests of palisaded basaloid cells with central comedonecrosis, hyalinised stroma. papillary > 70 exophytic or papillary malignant epithelial fronds with focal invasion at the...
Immunophenotype
In general an antibody panel is used with both expected positive and negative antibodies, and two antibodies per lineage. Commonly used antibodies available for formalin-fixed, paraffin-embedded sections are pan-lymphoid and excellent in the characterization of a poorly differentiated malignant tumour, e.g. lymphoma vs. carcinoma vs. melanoma. routine B-cell marker. lymphoma cell positivity is a marker for specific rituximab monoclonal antibody therapy. as for CD20 but also less mature (pre-B)...
Large cell carcinoma
no evidence of squamous or glandular differentiation although they probably represent undifferentiated forms of these. giant cell, clear cell, lymphoepithelioma-like, basaloid and neuroendocrine variants. In primary clear cell carcinoma (rare) exclude clear cell change in squamous or adenocarcinoma, secondary thyroid, salivary or renal cell carcinoma, malignant melanoma and benign clear cell (sugar) tumour of lung (HMB-45 and glycogen positive) a perivascular epithelioid cell tumour (PEComa)).
General
Capella C, Heitz PU, H fler H, Solcia E, Kl ppel G. Revised classification of neuroendocrine tumours of the lung, pancreas and gut. Virchows Arch 1995 425 547-560. Day DW, Jass JR, Price AB, Shepherd NA, Sloan JM, Talbot IC, Warren BF, Williams GT. Morson and Dawson's Gastrointestinal Pathology, 4th edn. Blackwell Science. Oxford 2005. Fenoglio-Preiser CM, Noffsinger AE, Stemmermann GN, Lautz PE, Listrom MB, Rilke FO. Gastrointestinal Pathology. An Atlas and Text, 2nd edn. Lippincott Williams...
Implants
epithelial atypia +borderline ovarian serous lesion (rarely, mucinous). The implants are assessed independently of the ovarian tumour as non-invasive or invasive (destructive infiltration of underlying tissue disrupting the omental lobular architecture), and epithelial (proliferative) or desmoplastic (stromal > 50-75 loose stroma granulation tissue with small nests or papillae of epithelial cells). Probably represent multifocal neoplasia arising in peritoneal inclusions. Endosalpingiosis,...
Borderline low malignant potential
serous lesions are of excellent prognosis regardless of stage and are bilateral in 20-25 occurring in a younger age group (40-50 years). They form 10-15 of epithelial tumours comprising epithelial complexity with budding, atypia, mitoses and nuclear layering (< 3 nuclei deep in mucinous lesions) but no destructive stromal invasion. Peritoneal recurrence in 10-15 . The outlook for mucinous borderline tumours depends on the subtype, i.e. endocervical (good) or intestinal (worse). NB...
Comments On Retroperitoneum
The retroperitoneum contains the kidneys, adrenal glands, ureters, aorta, inferior vena cava, vessel tributaries, lymph nodes, nerve plexuses and autonomic ganglia. Due to its inaccessible anatomical location tumours can attain a considerable size before clinical presentation with vague symptomatology or because of pressure effects on adjacent structures, e.g. ureter. Investigation is by CT scan supplemented by ultrasound and MRI as appropriate. Arteriography may be used if resection of a large...
Prognosis
Prognosis of ovarian carcinoma relates to morphological features such as histological type and grade, volume percentage epithelium and mitotic activity index as well as large volume of disease after cytoreduction, highvolume ascites and high postoperative CA125 levels. Overexpression of markers such as p53 and Her-2 may also be adverse but the predominant factor is stage of disease with the degree of extraovarian spread and omental involvement. Early stage disease confined to the ovary or...
B Endocrine islet cell tumours
arise from pluripotential ductal cells showing neuroendocrine differentiation. forming a minority of pancreatic neoplasms (1-5 ) usually occurring in adults. Small (< 1-2 cm), circumscribed and solid trabecular gyriform glandular cell patterns with hyaline ( amyloid) stroma. The majority are benign insulinomas (80-90 ). Prognosis depends on the functional subtype, adequacy of surgical excision and the extent of disease. 1. Functional hormonal syndrome (60-85 ) gastrinoma pancreatic head,...
Ampulla
adenocarcinoma. 80 of cases are usually of well to moderately differentiated intestinal pattern arising from adenomatous dysplasia in the peri- intra-ampullary mucosa. Endoscopic biopsy underestimates the nature and extent of disease yielding a positive diagnosis of malignancy in only about 40 of cases. It samples the surface dysplasia but not the underlying carcinoma, which is better demonstrated as a mass lesion on imaging (ELUS, CT). papillary adenocarcinoma. Exophytic, well differentiated...
Characteristic Lymphomas
Precursor B cell lymphoblastic lymphoma leukaemia. presents as childhood leukaemia or occasionally solid tumour (skin, bone, lymph node) and relapses in CNS testis. 75 survival in childhood but only 20 in adults. medium sized round lymphoid cells with small nucleolus, mitoses. CD79a, CD10, tdt, CD99 , Ki-67 > 95 , CD20 . B-cell lymphocytic lymphoma chronic lymphocytic leukaemia (CLL) adults with diffuse lymph node, bone marrow and blood involvement. small lymphocytes with pale proliferation...
Springer
Allen, MD, FRCPath Consultant Pathologist Histopathology Laboratory Belfast City Hospital Trust Belfast, UK Artwork marked with following symbols throughout the book is original to the following Springer titles and is being republished in this 2nd edition IQA Allen DC. Histopath Reporting, 1st edition. Springer-Verlag London Limited 2000 W Wittekind C, et al. TNM Atlas, 5th edition. Springer-Verlag Berlin Heidelberg 2005 British Library Cataloguing in Publication Data A catalogue...
Insitu carcinoma
bound by basement membrane involving > 2 ducts or 2-3 mm diameter. Epithelial proliferation of lesser extent is designated atypical ductal hyperplasia unless of high cytological grade or with comedonecrosis. nuclear grade low, intermediate, high. low is monomorphic evenly spaced cells with small central nuclei, few mitoses and necrosis is rare high is pleomorphic irregularly spaced cells with large irregular nuclei, coarse chromatin, > 1 prominent nucleolus, mitoses and often necrosis....
Hodgkins lymphoma
Comprising nodular lymphocyte predominant Hodgkin's lymphoma (NLPHL a B-cell lymphoma) and classic Hodgkin's lymphoma encom- Table 35.1 WHO REAL Classification of lymphoid neoplasms B-cell neoplasms Precursor B-cell neoplasms Precursor B-lymphoblastic lymphoma leukaemia Mature B-cell neoplasms Chronic lymphocytic leukaemia small lymphocytic lymphoma B-cell prolymphocytic leukaemia Lymphoplasmacytic lymphoma Waldenstrom's macroglobulinaemia Extranodal marginal zone B-cell lymphoma of...
Extranodal Lymphoma
Of NHLs, 25-40 are extranodal, defined as when a NHL presents with the main bulk of disease at an extranodal site usually necessitating the direction of treatment primarily to that site. In order of decreasing frequency sites of occurrence are gastrointestinal tract (especially stomach then small intestine) A majority are aggressive large B-cell lymphomas, although T-cell lesions also occur (cutaneous T-cell lymphoma, enteropathy-associated T-cell lymphoma, NK T-cell sinonasal lymphoma). Their...
Scoring system Quick score
In the Quick score, the proportion of cells staining and their intensity are 5 67-100 nuclei staining Intensity 0 no staining Adding the two scores together gives a maximum score of 8 with the likelihood of anti-oestrogen responsiveness being 0 hormonal therapy will not work 2-3 a small (20 ) chance of treatment response 4-6 an even (50 ) chance of treatment response 7-8 a good (75 ) chance of treatment response Currently the Quick score is the recommended method of assessment. Individual...
Immunophenotype miscellaneous markers for breast cancer
Ki-67 proliferation index (percentage positive cells), Her-2, p53, DNA ploidy. decreased survival is associated with tumours that are ER PR negative, DNA aneuploid, overexpress p53 Her-2 and have a high proliferation index. cytokeratin (CAM5.2, AE1 AE3, CK7), GCDFP-15, EMA, CEA positive. Variably positive for HMB-45, S100 and vimentin. cytokeratin 7 positive 20 negative the reverse of this is seen in intestinal tract tumours and this can be useful in metastatic carcinoma of uncertain origin,...
Lymphoma
predisposing conditions are ulcerative colitis and AIDS (which can also result in Kaposi's sarcoma). of probable mucosa-associated lymphoid tissue (MALT) origin (> 70 ) with a heterogeneous, polymorphous cell population low-grade < 20 blasts high-grade > 20 blasts and on a spectrum with diffuse large B-cell lymphoma. B (> 90 ) or T cell high content of eosinophils. prognosis relates to the grade and stage of disease. Others (see Chapter 4) centrocytic or mantle cell lymphoma (multiple...
Lymph Node Cancer
Bone marrow pathology. Blackwell Scientific. Oxford 1992. Banerjee SS, Verma S, Shanks JH. Morphological variants of plasma cell tumours. Histopathology 2004 44 2-8. Buley ID. Cytology of metastatic neoplasms in lymph nodes. In Lowe DG, Underwood JCE (eds). Recent advances in histopathology 18. Churchill Livingstone. Edinburgh 1999 116-118. Chan JKC. Tumours of the lymphoreticular system including spleen and thymus. In Fletcher CDM (ed). Diagnostic Histopathology...
Differentiationgrade
based on the degree of resemblance to adult mesenchymal tissues, cytological atypia, necrosis and mitotic activity with grade 1 well differentiation equating to low-grade, and grade 2 moderate and grade 3 poor differentiation to high-grade. Low-grade high-grade. Some lesions define their own grade by way of their inherent clinical behaviour high-grade Ewing's sarcoma peripheral neuroectodermal tumour (PNET), rhabdomyosarcoma (except spindle cell and botyroid types), angiosarcoma, pleomorphic...
Cervix
Tumours of the uterine cervix that can be underdiagnosed or misinterpreted. Curr Diagn Pathol 2003 9 56-70. Arends MJ, Buckley CH, Wells M. Aetiology, pathogenesis, and pathology of cervical neoplasia. J Clin Pathol 1998 51 96-103. Coleman DV, Evans DMD. Biopsy pathology and cytology of the cervix, 2nd edn. Arnold. London 1999. Herbert A. BSCC terminology for cervical cytology two or three tiers Why not five, seven or even 14 Cytology 2004 15 245-251. Histopathology reporting in...
Adenocarcinoma
15 (50 of lung cancer in females and also in non-smokers) of cases. 35 endobronchial, 65 peripheral, 75 involve the pleura at presentation and unusually can give a pseudomesotheliomatous picture. Central scar. Higher resectability rates than squamous carcinoma. solid with mucus formation (> 5 PAS AB-diastase positive cells in at least 2 hpfs). bronchioloalveolar peripheral single multiple or pneumonic infiltrate with lepidic spread along alveolar walls and no stromal, vascular or pleural...
Posttransplant lymphoproliferative disorder PTLD
EBV-associated spectrum of lymphoproliferation (immortalized B cells) following (first 2 years) immunosuppression for solid organ or bone marrow transplantation and occurring in the native or transplant lung. can respond to reduction of immunosuppression and antiviral therapy. early (plasma cell hyperplasia), polymorphous (infectious mononu-cleosis-like) or monomorphic (as in large B-cell lymphoma) stages. Also shows angioinvasion and necrosis. monomorphic monoclonal lesions are worse...
Malignant lymphoma
secondary to systemic nodal disease or primary (commoner) in the stomach it is the commonest site for extranodal non-Hodgkin's lymphoma (40 of cases). Primary disease bulk is centred on the stomach and its regional nodes. It can present as single or multiple lesions, a sessile plaque or thickened folds found incidentally at endoscopy, an ulcerated tumour or a thickened non-expansile stomach. The majority are of B-cell MALT (mucosa-associated lymphoid tissue) type, the low-grade variant being...
Germ cell tumours
20 of mediastinal tumours cysts. thymus based with a primary origin in extragonadal germ cells. exclude metastases from a clinical or occult testicular ovarian germ cell tumour, particularly if there is associated retroperitoneal disease. mature cystic teratoma the commonest mediastinal germ cell tumour and similar to that in the ovary. immature teratoma rare immature epithelium, mesenchyme or neural elements. mature and immature teratoma generally have a benign course if completely resected...
Primary peritoneal carcinoma
young to middle-age females. serous adenocarcinoma in type (CK7 WT1 ER positive). extensive peritoneal disease an ovarian serosal component with otherwise normal ovaries (any ovarian invasion < 5 mm2). treated by surgical cytoreduction and chemotherapy. The psammoma-tous-rich carcinoma variant has a better prognosis and indolent course. from primary ovarian carcinoma, usually forms either macroscopi-cally obvious confluent tumour nodules or a diffusely thickened omental cake.
Circumscribedirregular 2 Histological Type Adenocarcinoma
enteric pattern, well or moderately differentiated usual type. anaplastic (poorly differentiated) forms also occur more frequently than in colorectal cancer. mucinous carcinoma > 50 of the tumour area. signet ring cell carcinoma > 50 of the tumour cells. Diagnosis of primary small intestinal adenocarcinoma is by exclusion of spread from more common sites, e.g. colorectum and stomach. Similar to the large intestine there is some evidence for a dysplasia (adenoma)-carcinoma sequence in the...
Polyps
hyperplastic usual type, often antral and regenerative in nature. A 1-3 risk of malignancy* particularly if large (> 2cm) and multiple. *Either within the polyp or elsewhere in the stomach. fundic gland cyst very common. Association with colorectal pathology of various types (rare), familial adenomatous polyposis coli (FAPC) and proton pump inhibitor therapy (due to parietal cell hyperplasia secondary to hypergastrinaemia). Rarely dysplastic (FAPC). adenomatous 8 of cases with a 30-40 risk...
Preface to the second edition
Many of the introductory comments in the first edition of this book regarding the increasingly focused approach required of pathologists to surgical cancer histopathology reports still pertain. In the intervening period a number of trends have continued to develop that have required an update. system-specific cancer multidisciplinary meetings with specialized clinicians and appropriate pathological, radiological and oncological support. Increasingly these meetings require fewer pathologists...
Adjuvant therapy
adjuvant radio- chemotherapy induced tumour regression colitis. Postoperative adjuvant therapy is used for Dukes' C carcinomas and bad Bs, i.e. Dukes' B carcinomas with perforation, involved serosa, involved deep margin or extramural venous spread. These parameters score 2, 1, 1 and 1, respectively, with a total of > 2 necessitating postoperative chemotherapy. In rectal cancer international trials are examining whether treatment should be chemotherapy or radiotherapy in isolation or...
Pancreas
ductal adenocarcinoma (80-90 of cases) tubulo-acinar pattern of malignant ductal epithelium in a desmo-plastic stroma with perineural invasion and dysplasia of the adjacent duct epithelium (20-30 ). Pancreatic intraepithelial neoplasia (PanIN) is a microscopic papillary or flat, non-invasive epithelial neoplasm (dysplasia) comprising cubocolumnar epithelial cells with variable degrees of cytoarchitectural atypia. It usually arises in pancreatic ducts < 5 mm diameter, is multifocal and seen...
Thyroid Gland Tumours with comments on parathyroid
fine needle aspirate partial or (sub)total thyroidectomy left or right neck dissection. thyroid gland tumours usually present with enlargement due to a solitary cold nodule with euthyroid function. Differentiated (papillary, follicular) cancer may present with cervical lymph node or sclerotic bone metastases. Undifferentiated cancers are often of rapid onset with symptoms due to infiltration or compression of local structures, e.g. hoarseness, dysphagia or respiratory stridor. FNA is the...
Thymoma
anterosuperior mediastinum. solid, yellow grey, lobulated cystic change 80 are encapsulated and easily excised, 20 are infiltrative. It comprises a dual population of cytokeratin positive epithelial cells and T marker (CDs 1, 3, 4, 8, 99, 1a) positive lymphocytes of variable maturity. Classification which can reflect invasiveness and prognosis relies on 1. the character of the epithelial cells and lymphocytes 2. the relative proportion of these cells 4. the organoid architecture lobulated...
Scoring system Histo Score
In the Histo score, each cell is assessed as The percentage of cells showing each intensity of staining is estimated over as much of the section as possible and the Histo Score is calculated by multiplying the intensity score by the percentage of tumour cells showing that intensity e.g. a tumour with 50 of cells strongly stained, 25 moderately stained and 25 weakly stained would score (50 x 3) + (25 x 2) + (25 x 1) 225. Histo Scores < 75 are considered to be ER negative and those > 75 are...
Retinoblastoma
in bilateral cases the eyes are classified separately. The classification does not apply to complete spontaneous regression of the tumour. endophytic, exophytic (subretinal) or retinal spread. pT1 tumour confined to retina, vitreous, or subretinal space. No optic nerve or choroidal invasion pT2 minimal invasion of optic nerve or optic coats or focal invasion of choroid a. tumour invades optic nerve up to, but not through, the level of lamina cribrosa b. tumour invades choroid focally c. tumour...
Anatomical Clark level
increasing levels of invasion are associated with decreased survival, although it may simply reflect thickness of the lesion. I intraepithelial II papillary dermis III papillary-reticular interface papillary dermis filled and expanded down to an interface marked by the position of the superficial vascular plexus IV reticular dermis V subcutaneous fat. pTis melanoma in situ (Clark level I) severe melanocytic dysplasia pT1 tumour < 1 mm in thickness a. Clark level II or III, without ulceration...
Malignant polyps
Therapeutic polypectomy if the adenocarcinoma is (a) well or moderately differentiated (c) without lymphovascular invasion. (a) poorly differentiated (22 )* (b) at (< 1 mm) the stalk base (11 )* (c) shows lymphovascular invasion (18 )*. Resection is more likely if the patient is young and medically fit to obviate the risk of nodal metastases which can occasionally occur with pT1 lesions (4 ). A not uncommon finding is stalked adenomas in the sigmoid colon that twist and prolapse, resulting in...
Lobular carcinoma in situ
uniform cells populating the lobule. > 50 of the acini in the lobule expanded and filled. Pagetoid spread into ducts. potentially multifocal (70 ) and bilateral (30-40 ). epithelial proliferation of lesser extent (e.g. with preservation of lumina) is designated atypical lobular hyperplasia. Figure 22.2. Ductal carcinoma in-situ (DCIS) versus atypical ductal hyperplasia (ADH) versus florid hyperplasia without atypia (FHWA) cytology and histology. DCIS features smooth, punched-out luminal...
Introduction
Histopathology reports on surgical cancer specimens are becoming increasingly complex for many reasons. With closer clinicopathological correlation and the use of novel immunocytochemical and molecular techniques, new entities and classifications of tumour emerge that are linked to prognosis and response to various treatment modalities. Increasingly the surgical oncologist wants tissue biopsy proof of cancer diagnoses so that patients may be recruited to suitable treatment protocols. No longer...
Breast Cancer
Spindle cell tumours of the breast practical approach to diagnosis. Histopathology 1999 35 1-13. Anderson TJ, Page DL. Risk assessment in breast cancer. In Anthony PP, MacSween RNM (eds). Recent advances in histopathology 17. Churchill Livingstone. Edinburgh 1997 69-91. Bloom HJG, Richardson WW. Histological grading and prognosis in breast carcinoma a study of 1049 cases of which 359 have been followed for 15 years. Br J Cancer 1957 11 359-377. Boecker W, Buerger H. Usual and...
Figotnm
FIGO is based on surgical staging, TNM on clinical and or pathological classification. The TNM classification applies only to carcinomas. pTis carcinoma in situ ( CIN III or adenocarcinoma in situ high-grade CGIN) pT1 carcinoma confined to the uterus (extension to the corpus is disregarded) 1a lesions detected only microscopically maximum size 5 mm deep and 7 mm across venous or lymphatic permeation does not alter the staging Ia1 < 3mm deep, < 7mm horizontal axis Ia2 3 mm < tumour depth...
Bone And Soft Tissue Cancer
Practical morphological approach to the diagnosis and differential diagnosis of soft tissue sarcomas. Curr Diagn Pathol 2002 8 395-411. Bullough PG. Orthopaedic Pathology, 4th edn. Mosby Wolfe. St Louis 1998. Coffin CM, Lowichik A, Zhou H. Treatment effects in paediatric soft tissue and bone tumors. Am J Clin Pathol 2005 123 75-90. Coindre J-M, Trojani M, Contesso G, David M, Rouesse J, Bui NB, Bodaert A, de Mascarel I, de Mascarel A, Goussot JF. Reproducibility of a...
Comments On Adrenal Gland
Metastatic carcinoma in the adrenal gland, particularly from lung, breast and kidney, is commoner than a primary neoplasm and usually detected by follow-up CT scan. Sometimes CT-guided needle core biopsy or FNA is used to make this distinction and more often primary adrenal neoplasms present either as a symptomatic or incidental mass or are characterized by their endo-crinological symptoms and signs and resultant biochemical profiles. Phaeochromocytoma is a contraindication to biopsy due to the...
Tumour Report Protocols
Association of Directors of Anatomic and Surgical Pathology guidelines checklists cancer sites adrenal, ampullary, anus, bone, brain and spinal cord, breast, cervix, colon, endometrium, extrahepatic bile ducts, extra-adrenal paragangliomas, eye, and adnexa, fallopian tube, gall bladder, gestational trophoblastic disease, larynx, lip oral cavity oropharynx, liver, lung, lymphoma, nose and paranasal sinuses, oesophagus, ovary, pancreas, penis, pleural mesothelioma, prostate, renal pelvis and...
Gastric Carcinoma
gastric cancer can present with anaemia, weight loss or dyspeptic symptoms. Investigation is by endoscopy with biopsy. Staging for local and distant disease includes ELUS endoluminal ultrasound tumour depth and nodal spread , CT scan chest, abdomen and pelvis, PET scan and peritoneal laparoscopy with cytological washings and biopsy. Non-regional disease is an indicator for palliative treatment including chemotherapy, and surgery if there is anatomical dysfunction, e.g. extensive ulceration and...
Ophthalmic Cancer
Malignant melanocytic tumours of the eye a study of histo-logic types in 111 cases. Trans Am Acad Ophthalmol Otolaryngol 1931 36 131-142. Campbell RJ. Histological typing of tumours of the eye and its adnexa, 2nd edn. WHO International histological classification of tumours. Springer. Berlin Heidelberg New York 1998. Lee WR. Ophthalmic histopathology. Springer-Verlag. London 1993. McLean IW, Foster WD, Zimmerman LE. Uveal melanoma location, size, cell type and enucleation as risk...
Comments On Pelvic Exenteration
In general pelvic exenteration is considered for locally advanced or recurrent pelvic malignancy in the absence of extra-pelvic metastases. degree of disease spread is assessed by CT scan pelvic and retroperitoneal lymphadenopathy, extra-pelvic metastases. MRI scan local cancer spread. PET CT scan detects metabolic activity in malignant tumours and is useful in localizing recurrent or metastatic disease. Figure 7.5. Pelvic exenterations. QA Figure 7.5. Pelvic exenterations. QA relevant...
Kidney
Amin MB, Amin MB, Tamboli P, Javidan J, Stricker H, Venturina MD-P, Deshpande A, Menon M. Prognostic impact of histologic subtyping of adult renal epithelial neoplasms. An experience of 405 cases. Am J Surg Pathol 2002 26 281-291. Bonsib SM. The renal sinus is the principal invasive pathway. A prospective study of 100 renal cell carcinomas. Am J Surg Pathol 2004 28 1594-1600. Davies DR. The reporting of renal cell tumours. CPD Bulletin Cellular Pathology 2000 2 40-45. Fleming S. Classification...
Respiratory And Mediastinal Cancer
Immunohistochemistry in the distinction between malignant mesothelioma and pulmonary adenocarcinoma a central evaluation of new antibodies. J Clin Pathol 2002 55 662-668. Attanoos RL. Management of small biopsies in pulmonary diseases. CPD Bulletin Cellular Pathology. 2000 2 138-141. Attanoos RL. Pitfalls in pulmonary pathology. Curr Diagn Pathol 2005 11 44-51. Attanoos RL, Gibbs AR. Asbestos-related deaths. Curr Diagn Pathol 2002 8 373-383. Attanoos RL, Gibbs...
Skin Cancer
Balch CM, Buzaid AC, Soong SJ, Atkins MB, Cascinelli N, Colt DG, Fleming ID, Gershenwald JE, Houghton A Jr, Kirkwood JK, McMasters KM, Mihn MF, Morton DL, Reintgen DS, Ross MI, Sober A, Thompson JA, Thompson JF. Final version of the American Joint Committee on cancer staging system for cutaneous melanoma. J Clin Oncol 2001 19 16 3635-3648. Banerjee SS, Harris M. Morphological and immunophenotypic variations in malignant melanoma. Histopathology 2000 36 387-402. Blessing K. Benign atypical naevi...
Headand Neck Cancer
My approach to oncocytic tumours of the thyroid. J Clin Pathol 2004 57 225-232. Anderson CE, McLaren KM. Best practice in thyroid pathology. J Clin Pathol 2004 56 401-405. Baloch ZW, Livolsi VA. Newly described tumours of the thyroid. Curr Diagn Pathol 2000 6 151-164. Barnest L, Eveson J, Reichart P, Sidransky D eds . World Health Organisation Classification of Tumours. Pathology and Genetics. Tumours of the Head and Neck. IARC Press. Lyon 2005. Barrett AW, Speight PM. Diagnostic...
Lip and Oral Cavity Carcinoma
fine needle aspirate diagnostic or wedge excision biopsy resection, e.g. glossectomy neck dissection. pathological lesions present either as a lump, ulcer, red or white mucosal patch and require biopsy to determine their nature. preoperative investigation of a mass will include plain X-ray, MRI and CT scan to assess local spread, bone destruction and or cervical nodal metastases. Local wedge excision shave excision of adjacent mucosa is used for small tumours of the lip and tip lateral border...
Oesophageal Carcinoma
oesophageal cancer usually presents with progressive dysphagia initially for solids and ultimately liquids. Investigation is by endoscopy and biopsy, and chest X-ray to detect any enlargement of the heart, mediastinal lymph nodes or lung lesion that may be causing extrinsic compression. For biopsy-proven cancer, staging for local and distant disease includes endoluminal ultrasound tumour depth and nodal spread , computed tomographic CT scan chest and abdomen and positron emission tomographic...
Salivary Gland Tumours
oral . conservative superficial radical parotidectomy, submandibulectomy, excision of oral tumour sublingual glands, or minor salivary glands of mucosal origin , neck dissection. salivary gland tumours present as persistent unilateral enlargement the majority of which are in the parotid gland and are benign. There is a higher incidence of carcinoma arising in the submandibular glands, sublingual and minor glands of the oral cavity. Investigation is plain X-ray for calculus , ultrasound scan...
Laryngeal Carcinoma
biopsy hemi- partial or total laryngectomy neck dissection. Typically presenting with hoarseness, investigation is by indirect laryn-goscopy with biopsy. Chest X-ray and endoscopy of the upper aerodi-gestive tract are done to exclude a concurrent cancer elsewhere. CT and MRI are used to stage the tumour and cervical lymph node enlargement necessitates FNA to establish if there are metastases. Tumour stage and fitness of the patient determine the appropriate choice of treatment, i.e....
Myometrium
proportion of wall involved lt 50 , gt 50 . if gt 50 on MRI scan a radical hysterectomy is considered. Extent of myometrial invasion relates to the histological type and grade of carcinoma. True myometrial invasion must be distinguished from expansion of the endo- myometrial junction look for a continuous line of myometrial vascular structures in a compressed atrophic myometrium and abnormal epithelium in pre-existing adenomyosis look for periglandular endometrial stroma-CD10 positive ....
Nasal Cavity and Paranasal Sinus Carcinoma
fine needle aspirate biopsy resection, e.g. rhinectomy, maxillectomy, ethmoidectomy, craniofacial resection neck dissection. weight g and size cm , number of fragments. Clinical presentation is with nasal obstruction, rhinorrhoea, epistaxis or facial pain. Investigation is by endonasal endoscopy with biopsy. Plain X-ray, CT and MRI scan can demonstrate and stage a soft tissue mass and any bone destruction. Tumour can be removed piece-meal by fibre-optic endoscopic sinus surgery FE S S or more...
Oropharyngeal Carcinoma with comments on nasopharynx and hypopharynx
fine needle laryngectomy neck dissection. weight g and size cm , number of fragments. Depending on the anatomical site of the lesion, patients can present with dysphagia, hoarseness, deafness, cranial nerve palsy or cervical lym-phadenopathy. Investigation is by endoscopy with biopsy and cervical node FNA to obtain a diagnosis. CT and MRI scan are used to assess local tumour spread and metastasis to the neck and elsewhere. Chest X-ray can detect concurrent lung cancer. Extent of resection...
