breast and partial GYN CAP and Lester gross Flashcards
Name 3 criteria distinguishing Well-Differentiated Endometrioid Endometrial Adenocarcinoma from EIN or Atypical Endometrial Hyperplasia
Irregular infiltration of myometrium associated with:
1) altered fibroblastic stroma (desmoplastic response)
2) loss of intervening stroma (confluent glandular, cribriform or labyrinthine pattern)
3) complex (villoglandular) or solid non-squamous epithelial growth
What is the basis of the T stage for endometrial carcinoma?
- Myometrial invasion (< or >= 50% thickness)
- Other tissue invasion (cervical stromal tissue, serosal surface, adnexa, …)
T1 = confined to uterus, (a/b) depth of invasion 50%
T2 = involving cervix stromal connective tissue
T3 = Involving serosa, adnexa (a) or vagina, parametrium (b)
T4 = involving bladder/bowel
What defines the 3 FIGO grading system used for endometrial carcinoma?
G1 = <=5% non-squamous solid growth pattern
G2 = 6 to < 50% non-squamous solid growth pattern
G3 = >50% non-squamous solid growth pattern
Severe cytologic atypia in the majority of cells (> 50%), which exceeds that which is routinely expected for the architectural grade, increases the tumor grade by 1.
The FIGO (international federation of Gynecology and obstetrics) grading system for uterine corpus is designed specifically for which subtype of endometrial carcinoma?
Endometrioid Ca
Mucinous Ca
Give 3 examples of endometrial carcinoma subtype which are NOT graded using the FIGO system.
All considered high-grade to start with:
- Serous Ca
- Clear cell Ca
- Transitional Ca
- Small cell neuroendocrine Ca
- Large cell neuroendocrine Ca
- Undifferentiated / dedifferentiated Ca
- Carcinosarcoma
- Mixed carcinoma (implies a serous or clear cell component)
- note that the squamous component of endometrioid carcinoma is not graded (parallels the glandular component)
Compare to the general population, the prevalence of LUS endometrial carcinoma is significantly increase in which syndrome?
Lynch syndrome
What are the 4 molecular subtype of endometrial carcinoma?
- POLE-ultramutated endometrioid carcinoma
- Mismatch repair–deficient endometrioid
carcinoma - p53-mutant endometrioid carcinoma
- no specific molecular profile (NSMP)
Name 3 biomarkers which can be assessed in endometrial carcinoma
1) MMR proteins (universal, to be perform in all subtypes)
2) ER (in advance stage carcinoma, to predict response to endocrine therapy)
3) HER2 (for serous subtype)
Which microscopic findings (pattern and IHC) do you expect for 1) endometrioid, 2) serous, 3) clear cell endometrial carcinoma
1) Endometrioid
- architecture: glandular, papillary, solid
- cell: differentiation is endometrioid, with some degree of squamous, mucinous or secretory
- loss ARID1A, PTEN, MMR
2) Serous
- architecture: glandular, complex papillae
- cell: high-grade feature
- abnormal p53, diffuse p16
3) Clear cell
- architecture: papillary, tubulocystic, solid
- cell: clear to eosinophilic cuboidal, polygonal, hobnail, or flat
- positive for HNF1beta, Napsin A, AMACR (P504S)
In high-grade endometrial tumors, squamous differentiation strongly favors which histological subtype over the other?
Endometrioid Ca
What IHC profile supports the diagnosis of undifferentiated endometrial carcinoma
Focal Pax8
Focal EMA
Focal Keratin
< 10% reactivity for neuroendocrine markers
vimentin +
ER, PR, ECAD -
May show MMR and/or BRG1 loss
Name 3 prognostic factors deemed important for endometrial carcinoma and which you should report.
- histological subtype
- tumor grade
- LVI (for regional & distant recurrence, and survival)
- Lymph node status
- depth of myometrial invasion
- invasion of other tissues (stromal connective tissue of cervix, uterine serosal surface, adnexa, bladder, bowel)
- stage
What is the minimal size recommended for a diagnosis of EIN?
1mm
Which % of endometrial carcinoma are attributed to Lynch syndrome
3-5%
According to NCCN guidelines, how does the grade of an endometrial carcinoma affects the accuracy of intraoperative evaluation of myometrial invasion (ie, assessment by gross examination of fresh tissue)?
As the grade of the tumor increases, the accuracy of intraoperative evaluation of myometrial invasion decreases (accuracy of 87% for G1, 65% for G2 and 30% for G3)
When should you report on margins in hysterectomy for endometrial carcinoma?
Only when the cervix and/or paracervical-parametrial tissue is involved by carcinoma
What are the only true margins (2) in total hysterectomy specimens?
Parametrial/paracervical soft tissue
Vaginal cuff
Does peritoneal washing influence the FIGO stage (endometrial carcinoma)?
No (not considered as an independent risk factor; should still be reported)
According to NCCN guidelines, what is the false-negative rate associated with endometrial biopsy?
10%
(thus, a negative result in a symptomatic individual should be followed by D&C)
Name 2 mimics of lymphovascular space invasion (LVSI) in endometrial carcinoma evaluation
1) retraction
2) MELF (microcystic, elongated and fragmented) pattern of invasion
3) artifactual displacement of tumor cells
Extent of LVSI is semi-quantitative in endometrial carcinoma. How is it quantified?
1) Low LVSI is < 3 vessel involvement
2) Extensive LVSI is >= 3 vessel involvement
Loss of immunoreactivity for which immunostains (name 3) may be a helpful diagnostic tool when considering the diagnosis of EIN?
PAX2
PTEN
mismatch repair proteins
Regarding gynecologic markers (ER, PR, etc), how do we report the results ?
1) intensity of immunoreactivity (weak, moderate, strong)
2) proportion of positive cells (%)
Regarding breast/gynecologic ER receptor testing, list 5 causes of false-negative IHC.
- Exposure of tumor cells to heat (cautery during surgery)
- Prolonged cold ischemic time (antigenic degradation, should be 1 hour or less)
- Under or overfixation (at least 6 hours)
- Type of fixative (neutral-buffered formalin recommended, ER is degraded in acidic fixatives such as Bouin’s and B-5)
- Decalcification
- Nonoptimized antigen retrieval (or use of (weeks) old tissue sections
- Type of antibody
- Dark hematoxylin counterstain obscuring faintly positive diaminobenzidine (DAB) staining
- Artefact (crush or edge artefacts)
The breast carcinoma is triple negative. What can you rely on to ensure the result is a true negative? Name 3 parameters/factors.
1) Internal control (normal epithelial cells) should be positive
2) External control should be positive
3) Results should be concordant with those expected based on histological type and grade of the carcinoma
4) Tumoral cells are present on the stained section
5) Specimen handling was adequate (cold ischemic time, fixation time, etc.)
Regarding breast/gynecologic ER receptor testing, list 2 causes of false-positive IHC.
1) use of an impure antibody that cross-reacts with another antigen
2) misinterpretation of entrapped normal cells or an in situ component as invasive
3) image analysis devices that mistakenly count overstained nuclei
In breast/gynecologic ER receptor testing, what is the cutoff value (%) of positive cells that should be classified as receptor positive?
> = 1%
What type of biomarker is HER2 in breast?
Both prognostic (bad, marker of aggressivity) and predictive (to herceptin/transtuzumab therapy)
1) On which chromosome if HER2 located, 2) what is its general function, and 3) against which gene is it tested in FISH to assess for its amplification?
1) Chromosome 17
2) Tyrosine kinase receptor from the EGFR family (key role in signaling pathway regulating cell division, proliferation, differentiation, apoptosis)
3) CEP17 (HER2/CEP17 ratio > 2.0 usually)
1) On which chromosome is p53 located, 2) what is its general function, 3) what type of biomarker is it for the gynecologic tract, and 4) which endometrial carcinoma show abnormal p53 pattern?
1) Chromosome 17
2) Tumor suppressor protein that induces expression of p21, a cyclin-dependent kinase inhibitor that
is involved in the arrest of cellular proliferation at the G1 phase (key role for regulating cell proliferation, DNA repair, apoptosis and genetic stability)
3) diagnostic (for serous carcinoma), predictive (for targeted chemotherapy), prognostic (poorer outcomes)
4) Serous carcinoma (90%) and endometrioid carcinoma (10-40%)
What are the possible pattern of p53 IHC?
A) Wild type (nuclear expressed in a patchy fashion)
B) Abnormal-overexpressed (nuclear)
C) Abnormal-null
D) Abnormal-cytoplasmic (in addition to the nuclear staining)
Which 2 factors significantly affects p53 expression by IHC?
1) non-optimized antigen retrieval
2) use of archival (weeks old) tissue sections
Contrast Lynch syndrome, mismatch repair protein (MMR) and microsatellite instability (MSI)
Lynch syndrome is caused by germline mutations in MMR genes. Defects in MMR also cause MSI. MSI is an hallmark of Lynch, but is not specific to this syndrome.
To screen for Lynch, one may perform:
1) IHC, assessing MMR protein expression
2) DNA short tandem repeats analysis, assessing MSI*
3) Germline mutation analysis
Methods 1 and 2 are surrogate markers of Lynch. Option 3 should be performed by the genetic team.
- MSS / MSI-low / MSI-high can be viewed respectively as negative / equivocal / positive result indicating high-probability of Lynch syndrome. CAP recommends that if only MSI was performed, IHC should be done to identify the most likely gene to have a germline mutation.
1) Which MMR anomaly by IHC is most often due to a sporadic event, and 2) which additional test can you perform to distinguish sporadic vs germline event?
1) MLH1 loss, which is often due to hypermethylation of its promotor, an epigenetic sporadic event NOT indicative of Lynch
2) Methylation-specific real-time PCR can determine the presence of methylation; alternatively, the presence of BRAF V600E mutation would suggest a sporadic event (this mutation is NOT seen in Lynch)
What type of biomarker is ER/PR in breast?
Weak prognostic factor (negative prognosis if negative) and good predictive factor (to hormone therapy; ex.tamoxifen)
In breast, false-positive IHC results for HER2 may be due to… name 2 factors
1) Edge artefact
2) Overstaining (strong membrane staining of normal cells, may be due to improper antibody titration)
3) Cytoplasmic positivity (obscure membrane staining)
4) Misinterpretation of DCIS as invasive component (DCIS usually positive)
In breast, false-negative IHC results for HER2 may be due to… name 2 factors.
1) prolonged cold ischemic time
2) tumor heterogeneity
3) improper antibody titration
Name the possible scores and explain the criteria for the reported results of HER2 testing by IHC in BREAST.
Name the possible scores and explain the criteria for the reported results of HER2 testing by IHC in GYNECOLOGIC.
Name the possible scores and explain the criteria for the reported results of HER2 testing by IHC in GASTRIC/GEJ.
Name 2 reasons why the ISH of HER2 may fail
- Prolonged fixation in formalin (>1 week)
- Fixation in non-formalin fixatives
- Procedures or fixation involving acid (decalcification) may degrade DNA
- Insufficient protease treatment of tissue
Name 3 roles attributed to fixation (Lester).
- Harden tissue
- Inactive infectious agent (except Creutzfeldt-Jacob)
- Preserve tissue
- Stabilize tissue components
- Enhance avidity for dyes
Name 2 disadvantages associated with fixation (Lester).
- Alteration of protein structure
- Solubility of tissue components (lipids and carbohydrate are often lost)
- Shrinkage of tissue
- DNA and RNA degradation (especially those containing picric acid)
1) What amount of fixative is considered adequate for a given tissue; 2) what is the speed at which fixative penetrates the tissue; 3) what amount of time is usually required for adequate fixation in formalin; 4) at which temperature is formalin fixation usually performed? (Lester)
1) 15 to 20 times the volume of the tissue
2) 0.1cm per hour (but written 0.4 cm/24h elsewhere)
3) 6-8 hours
4) Room temperature (Note that temperature increases the rate of fixation and rate of autolysis; it must be monitored carefully)
Name 6 factors affecting the preservation of a biomolecule (DNA, RNA, protein, etc.). (Lester)
1) Patient factors: disease state, drug, other treatment (radiation)
2) Surgical factors: time at which tissue is removed from blood flow, time the specimen is removed from patient, exposure to surgical instrument (cutting, cauterizing), length of time of surgery, time under anesthesia
3) Transport factors: length of time of transport to path department, condition during transport (fresh or fixed)
4) Pathology factors: length of time to fixation, thickness of sections & adequacy of fixation, type of fixative, length of time in fixation prior to processing of paraffin blocks,
processing protocols (dehydration, clearing, impregnation), type of paraffin, length of time in paraffin, conditions of block storage, time since slides were cut.
Name 4 types of fixative and for each, list color, one advantage and one disadvantage (Lester).
1) Formalin: clear; A = cheap, fixes most tissue well, compatible with most histologic stains, preserves tissue for months, required for visualization of lacunar cells of CHL; D = slow penetration rate (0.4 cm/24h), overfixation can diminish immunoreactivity, dissolve uric acid crystals and calcium phosphate in breast.
2) Bouin’s solution: yellow; A = sharp H&E staining, facilitate finding of LN (white on yellow background), prolonged fixation decalcify tissue; D= tissue brittle if fixed > 18h, colors specimen yellow, lyses RBC, dissolve iron and calcium deposits, contains PICRIC ACID which is EXPLOSIVE if dry and degrade DNA and RNA.
3) B-Plus: clear/blue; A = rapid fixation with excellent cytologic details, antigen preservation; D = same as formalin, contains ZINC which interferes with PCR.
4) Zenker’s acetic fixative: orange; A = rapid fixation with excellent cytologic details, slowly decalcify tissue, lyses RBC, useful to demonstrate chromaffin reaction in pheochromocytoma; D = poor penetration, tissue brittle if fixed > 24h, dissolve iron, contains MERCURY which interferes with PCR, requires washing tissue before processing, and is TOXIC.
5) Glutaraldehyde: clear; A = excellent preservation of ultrastructure cellular details; D = penetrate slowly and poorly, refrigeration required for storage, false-positive PAS stains.
6) Alcohol: clear; A = many antigen well preserved, no special disposal method required; D = dissolve lipids and penetrates poorly.
Which fixative should you use for the following specimens (Lester):
1) Bone marrow biopsy
2) Gout specimen
3) Muscle biopsy
1) Bouin or Zenker fixative
2) Ethanol
3) Snap frozen and placed into glutaraldehyde
According to CLIA, what is the recommended retention times for (Lester):
1) Gross specimen (wet tissue)
2) Paraffin blocks
3) Glass slides of tissue sections
4) FNA slides
5) Surgical pathology report
1) until diagnosis issued
2) 2 years
3) 10 years
4) 5 years
5) 10 years
List 2 instances where the clinician should be contacted before rejecting specimen (Lester)?
1) Unlabeled or sub-optimally labeled specimens
2) Inappropriate, soiled or leaking containers
3) Empty container
4) Markedly degraded specimen
Considering the universally accepted anatomical position, what surface on the penis corresponds to the dorsal/posterior surface (Lester).
The upper surface (the penis is erected in the anatomical position, with the upper surface of the penis considered the dorsal or posterior part of the penis).
Give 3 possible explanation to finding fewer than expected lymph node on resection (Lester).
1) Pathology factors : prosector did not found them
2) Patient factor: elderly patient, prior surgery.
3) Treatment factors: radiation and chemotherapy can decrease the numbers
4) Surgical factors: specimen is small or doesn’t contain enough lymph node to start with.
- Note that certain diseases (rheumatologic diseases, carcinoma with medullary features) are associated with nodular lymphoid hyperplasia, making the lymph node easier to see.
Name 3 methods to estimate the volume of breast tissue involved by DCIS.
Reported as mm (+/- #blocks involved/examined), you can estimate the overall size by measuring:
1) DCIS in 1 block (if fits entirely in it)
2) Serial sequential sampling
3) Nonsequential sampling (x 4mm)
4) Margins
5) Gross lesion
What are criteria used to grade phyllodes tumor of breast?
Based on 5 features
1) stromal cellularity
2) stromal atypia
3) stromal overgrowth
4) tumor border
5) mitotic rate
Malignant requires: marked stromal cellularity, marked stromal atypia, stromal overgrowth, an infiltrative tumor border and ≥10 mitoses per 10 HPF.
*** Note that presence of malignant heterologous element OTHER than WELL-DIFFERENTIATED liposarcoma makes this a malignant phyllodes automatically.
List the 4 criteria for LVI in breast resection.
1) LVI located outside the invasive foci
2) Tumor doesn’t conforms exactly to the space
3) Space is lined by endothelial cells
4) Lymphatics are adjacent to blood vessels
Which type of tumor is most common in the ovary?
Epithelial tumor
Name the IHC profile of STIC
TP53 mutated (at least 12 consecutive epithelial cells expressing it), and ki67 > 10%
Which IHC panel would you recommend to distinguish the non-molar trophoblastic lesions from one another?
IHC: beta-hCG, p63, hPL, CD146, KI67, cyclin E
Note:
* beta3-HSD and LMWCK confirms trophoblastic origin
* in the image, the (-) sign indicate (-, may sometime be (+))
