Samia Nawaz, MD Associate Professor

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Surgical Pathology Unknown CasesMonday Conference
December 11th, 2006
Samia Nawaz, MD Associate Professor Department
of Pathology University of Colorado at Denver
Health Science Center, Denver, Colorado And
Veterans Administration Hospital in Denver
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CASE 1

• 54 year old male with jejunal mass

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DESMIN
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CD34
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CD117
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CD117
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CASE 1 DIAGNOSIS

• GIST ( gastro-intestinal stromal tumor)
• Dumbbell shaped 2.5cm on serosal side and 3.5cm
  on mucosal side with ulceration.
• Proximal distil margins negative
• Peripheral margin positive
• Positive for CD117 and SMA
• Negative for S100, CD34 and desmin

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GIST

• What cells are these?
• Smooth muscle?
• Nerve sheath?
• Fibroblast?

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GIST

• Intestinal cells of Cajal
• GI pace maker cells (control peristalsis)
• Intercalated between smooth muscle and autonomic
  nerves
• for C kit proto oncogene which encodes for a
  trans membrane tyrosine kinase receptor

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GIST

• Stomach, small intestine (esophagus, colon)
• Age40-80, MF
• Stomach nausia, anorexia, bleeding
• Sm bowel obstruction, abd pain, bleeding

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GIST

• Gross round, dumbbell, circumscribed or
  infiltrative, surface ulceration, myxoid change,
  cyst formation
• Micro spindled cells
• epitheliod cells
• mixed cell type

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GIST

• Benign or malignant?

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GIST

• Benign, LMP, HMP, malignant
• Malignant potential
  mitotic count and size
• In small bowel presence of any mitoses HMP

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GIST

• Carneys triad
• GIST
• pulmonary chondroma
• pheochromocytoma

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CASE 2

• 62 year old male with 30 lb weight loss

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Case 2 Diagnosis

• Diffuse gastric Ca, poorly diff with signet ring
  features
• 7.5 cm
• All surgical margins negative
• 12/29 LN with met CA

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Gastric neoplasia

• Gastric Dysplasia
• Early gastric Ca
• Intestinal gastric Ca
• Diffuse Gastric Ca

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Gastric Ca

• Intestinal Type
• intest metaplasia
• Atrophic gastritis
• Glandular/papillary
• Extracytoplasmic mucin

• Diffuse Type
• - Intest metaplasia
• -Atrophic gastritis
• Diffuse pattern
• Intracytoplasmic mucin

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CASE 3

• 71 year old male with pancreatic mass

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Peri-Ampullary AdenoCa

• Tumors in vicinity of ampulla of Vater Distil
  CBD, ampullary complex, pancreas, duodenum
• Not common
• Usually well diff
• Obstructive jaundice, pancreatitis
• locally resectable

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CASE 3 DIAGNOSIS

• Mod diff adenoca arising in ampulla of Vater
  extends into duodenal wall but not into pancreas
• Margins clear
• 0/13 Lymph Nodes

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CASE 4

• 48 year old male , had FNA of pre-auricular mass
• Followed by its resection with R neck dissection
  and R hemi-mandibulectoomy

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CASE 4 DIAGNOSIS

• Adenoid cystic CA involving 3/18 nodes and almost
  complete replacement of mandible bone

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Adenoid cystic Carcinoma

• 50-70 years age, MF
• 3 characertictics
• histologic appearance
• Slow growth
• Facial N paralysis

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ACC

• Lacrimal gland 50
• Submandibular 15
• Parotid 5
• Minor salivary glands, palate

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Adenoid cystic Ca

• Cribriform
• Tubular
• Solid
• Most cases mixed pattern
• Prognostic differences

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Prognosis

• Major problems
• local control, but potential for recurrence
• Metastases lung, nodes, bone
• Slow growth favorable 5 year SR but unfavorable
  long term SR

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Differential Dx

• adenoCA NOS
• Epithelial-Myoepithelial Ca
• Polymorphous lowgrade Ca
• Salivary duct CA
• Pleomorphic adenoma
• Basal cell adenoma

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CASE 5

• 48 year old male with multiple pulmonary nodules

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CASE 5 DIAGNOSIS

• Metastatic salivary duct CA
• Positive for EGFR
• Her2 neu not amplified ( FISH)

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Salivary Duct Ca

• High grade epithelial Ca
• From excretory ducts
• Resembles ductal Ca breast

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Salivary Duct Ca

• Differntial Dx
• Mucoepidermid Ca
• Acinic cell Ca
• Met breast Ca

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CASE 6

• 63 year old male with recurrent pleural effusions

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Case 6Additional studies

• Positive
• calretinin, panCK, CK5/6
• Negative
• TTF1,CD15,BerEP4,

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CASE 6 DIAGNOSIS

• Diffuse mesothelioma, epitheliod type with
  tubular and micropapillary formations
• focal involvement of visceral pleura and adjacent
  superficial lung parenchyma.
• Myxoid stroma better prognosis (Virchows
  Arch.2005Jul 141-7)

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Malignant Mesothelioma

• Epitheliod
• Spindled/sarcomatoid
• Mixed (biphasic)

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Malig Mesotheiolma vs AdenoCA

• Stain mesothelioma AdenoCA
• TTF1 -
• CD15 -
• BerEP4 -
• B72.3 -
• Calretinin -
• CK5/6 -

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J Clin Pathol.200255(9)662

• Antibody mesothelioma adeno
• TTF1 0 69
• Calretinin 80 6
• N-cadherin 78 26
• Thrombomodulin 53 6
• CK 5/6 63 6
• N 41 m mesoth and 35 lung adenoca

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CASE 7

• 78 year old male with recurrent pleural effusions

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CASE 7 additional studies

• Positive panCK, CK7,mucin, TTF1,
  BerEP4
• Negative Calretinin, CK20

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Pseudomesotheliomatous adenocarcinoma of R lung

• Rare subtype of adenoca
• Clinical, radiologic and gross appearance s/o of
  mesothelioma
• Microscopic inconclusive
• Dx based on stains

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Histopathology 2003 Nov,43(5)44-52

• 53 cases (50M, 3F) over 10 yr period
• Age 33-77 ( median 68)
• H/o smoking in 46 cases (87)
• H/o asbestos in 40 cases ( 76)
• Survival poor ( median 8m)
• 2 groups primary lung adeno (n47)
• metastatic ca (n6)
  (2TCC,1RCC,1prostate, 1parotid, 1pancreatic)

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