GI and Liver Flashcards
Pink Inclusions in Hepatocytes
Non-neoplastic:
Apoptotic bodies
Mallory hyaline
Fibrinogen
Megamitochondria
Congenital:
Alpha 1 antitrypsin
Glycogen storage disorder
Neoplastic: HCC, embryonal sarcoma
Neutrophils in Liver
Non - Neoplastic:
“surgical hepatitis”
CMV
Ascending cholangitis
NASH / ASH
Neoplastic: in association with malignant tumours, both primary and secondary
Liver Special Stains
Reticulin: Architecture, plate thickness
Trichrome: Staging of fibrosis
PAS: BM, AIAT globules, storage disorders
PERLS: presence, site, grading of iron
Rhodanine: Copper deposition (Wilson, cholestasis)
Orcein: elastic fibres, Cu associated binding protein, Hep B surface antigen
Subtypes of HCA
1) HNF1A inactivated (loss of LFABP)
2) Inflammatory adenoma (express CRP / SAA in 50%)
3) Beta catenin activated. (nuclear BCat of diffuse GS)
4) SHH activated (ASS1 +, increased risk of bleeding)
5) Unclassified
IPX for Primary Liver Carcinoma
HCC: HepPar1, arginase +, CK 7 / CK 20 -
CC: CK7 / CK 19 +, albumin RNA ISH +
HCA versus Well Diff HCC
HCA:
Younger, female, hormones, non cirrhotic
Bland cytology, no reticulin loss, low Ki67
Glypican and HSP70 negative
HCC:
Older, cirrhotic or chronic liver disease
Glandular / acinar formation, loss of reticulin network
Increased atypia and mitoses
Ki67 increased c.f. background
Glypican 3 and HSP70 positive
DDx Granulomas in the Liver
PBC
Sarcoidosis
Infection (Hep C, Tb, atypical Mb)
Drugs
Paraneoplastic syndrome
Idiopathic
MMR / BRAF in GI Cancers
Loss of MLH1 / PMS2
= promoter hypermethylation
or germline mutation (Lynch)
BRAF V600E positive = most likely promoter hypermethylation (sporadic)
Isolated loss of PMS2
Loss of MSH2 / MSH6
= most likely to be germline mutation
Synoptic Report Malignant Polyps
Site and size of polyps, pedunculated or sessile
Precursor polyp type
Histologic type of cancer
Histologic grade
Size of invasive carcinoma
LVI
PNI
Tumour budding score
Margin status
MMR / BRAF
Other: NE markers, Ki67 as needed
Haggitt versus Kikuchi
Haggitt =
Adenocarcinoma in a pedunculated polyp
Four levels: depth of invasion from head of stalk to submucosa (level 4)
Kikuchi =
Adenocarcinoma in a sessile polyp
Three levels: depth of invasion within submucosa (sm1 - 3)
Explain how to Cut Up This Specimen
- PPE, 3 points of ID, orient and photograph
- Review MDM and imaging (where is tumour located, size)
- Measure stomach, duodenum, pancreas, ducts, gallbladder, fat. Open stomach / duodenum and fix.
- Ink pancreatic margin, SMV / vascular groove, uncinate (SMA)
- Take margins: stomach, duodenum, bile duct and pancreatic margin
- Section superior to inferior, lay out slices and photograph
- Describe tumour - border, size, cut surface distance to margins
- Block tumour to closest margins and anatomy documenting this on photo blocking diagram
- Look for lymph nodes
Explain how to cut up this Specimen
- PPE, 3 points of ID, orient and photograph
- Review MDM notes / imaging ? site, size of tumour, relationship to structures, prior NAT
- Measure length and diameter of specimen, width of mesocolon to apical tie, measure distance of PPR and APR to distal margin. Comment on completeness of mesorectum and ink mesorectum. Open and fix.
- Margins from proximal, distal and apical tie including apical lymph node.
- Look for polyps, diverticulae / other pathology.
- Measure tumour, distance to proximal and distal margins and relationship to anterior peritoneal reflection.
- Slice from superior to inferior, lay out slices of tumour and photograph. Describe depth of invasion and closest CRM.
- Block 6 - 8 blocks of tumour - background polyp, depth of invasion and closest CRM. Document on photo blocking diagram.
- Look for lymph nodes.
Explain how to cut up this Specimen
- PPE, 3 points of ID, orient specimen.
- Review MDM notes and imaging - ?size / site of tumour, relationship to adjacent structures, NAT
- Measure lesser curve, greater curve, width, proximal and distal resection margins, omentum in 3 dimensions. Inspect serosal surface.
- Ink circumferential resection margin. Open along greater curve and pin out on board to fix.
- Photograph specimen. Describe gastric mucosa including site, size, appearance of tumour. Measure tumour to proximal and distal margins. Take shave margins to prox and distal.
- Section stomach through tumour. Lay out slices and photograph. Describe deepest point of invasion and distance to circumferential resection margin.
- Block tumour to closest margins and anatomy. Block background mucosa. Record on photo diagram.
- Look for lymph nodes.
Syndromes Associated with GI Polyps and Tumours
1. Lynch: AD, MMR proteins
- colorectum, stomach, small bowel, pancreaticobiliary, endometrial, ovary, upper urothelial tract
2. Muir-Torre: AD, MSH2, MLH1
- phenotypic variant of Lynch, sebaceous adenomas and carcinomas and keratoacanthomas
3. FAP: AD, APC
- Small and large intestine, periampullary adenocarcinoma, fundic gland polyps with dysplasia in stomach. Cribiform morular thyroid neoplasms. Nasopharyngeal angiofibromas in males.
Gardner - variant of FAP, adenomas plus: soft tissue and ovarian fibromas, fibromatosis, osteomas, supernumerary teeth
4. Turcot: variant of FAP or Lynch. Either:
Medulloblastoma plus FAP or
GBM and Lynch.
Other:
Serrated polyposis syndrome
Peutz Jegher syndrome
Juvenile polyposis syndrome
Cowden (PTEN hamartoma) syndrome
Cronkhite-Canade syndrome
Herediatry diffuse gastric cancer syndrome
Syndromes Associated with GIST
1. Carney - Stratakis syndrome (AD, SDH genes)
- SDH deficient GIST
- Paragangliomas
- SDH deficient RCC
2. Carney Triad (SDHC hypermethylation)
- SDH deficient GIST
- Paragangliomas
- Pumonary chondromas
3. NF1
4. KIT and PDGRFA mutated syndromic GIST’s