Heart and Lung Flashcards
DDx Big Pink Nodules in Lung
Granulomas (necrotising & non necrotising
Sarcoidosis
Rheumatoid nodules
Silicotic nodules
Nodular amyloidosis
LCH
Epithelioid haemangioendothelioma
Neuroendocrine Neoplasms in Lung
Typical carcinoid = Mitoses <2 per 2mm2 , no necrosis
Atypical carcinoid = Mitoses 2 - 20 per 2 mm2 , focal necrosis
Neuroendocrine carcinomas = Mitoses > 10 per 2mm2 , necrosis ++
NB: Ki67 not formally a part of WHO 2014 criteria, but expected cut offs for Ki67 are <2 and <20 and 20-100%
Molecular Biomarkers in Lung
Recommended Biomarkers for Non Squamous, Non Small Cell Lung Cancer (NCCN):
EGFR, ALK, ROS1, BRAFVE1, NTRK 1- 3, MET, RET
CAP also recommend: ERBB2 / HER2, MMR, KRAS
PDL1 if indicated
Describe the Macroscopic Dissection of this Specimen
- PPE, 3 forms of ID, orient specimen.
- Check MDM and PET - number of lesions, site, size, relationship to adjacent structures (pleura, chest wall, hilum)
- Inflate with formalin in biosafety cabinet and allow to fix for 24 - 48 hours
- Measure in three dimensions, measure and describe staple lines / margins at the hilum. Remove staples & ink margins.
- Identify hilar lymph nodes, measure and submit.
- Shave bronchial and vascular margins.
- Inspect pleura, ink any abnormalities.
- Section from superior to inferior into 4 - 5 mm slices. Identify tumour, measure in 3D and measure distances to bronchial, vascular and surgical resection margins. Describe cut surface and relationship to adjacent structures.
- Block tumour (all if <3cm), otherwise at 1 - 2 cm including closest pleura / fissure / hilar structures / margins.
- Examine background lung in more detail and submit approx 2 sections of this.
DDx Granulomas in Lung
Infectious:
Mycobacteria, atypical mycobacterial, fungal, parasites
Pneumoconiosis:
Aluminium, Berylium, Cobalt
Connective Tissue Disorders:
Rheumatoid arthiritis, GPA, EGPA
Immunodeficiency States:
CVID, chronic granulomatous disease
Other:
Sarcoidosis, hypersensititity pneumonia, hot tub lung, LIP
Eosinophilic pneumonia, aspiration pneumonia, IV talc
Drug effect, lymphoma, adjacent lung malignancy
Reporting Elements in Synoptic Report for Lung Cancer
Specimen type, laterality, number of primary tumours
Tumour site, size, histologic type
Histologic grade and patterns present
Spread through air spaces
Viscreal pleural invasion
Direct invasion of adjacent structures (main bronchus, hilar soft tissues, carina, parietal pleura, parietal pericardium, phrenic nerve, diaphragm, mediastinum, heart, g.vesssels)
Treatment effect
Lymphovascular space invasion
Margins
Nodes (hilar, mediastinal)
Metastases
Findings / Appearance of Background Lung
DDx Solitary Lung Lesion
NON NEOPLASTIC:
Congential: sequestration, bronchogenic cyst
Inflammatory: Granuloma, abscess, organising pneumonia, sarcoidosis, rheumatoid nodules, GPA
NEOPLASTIC:
Benign: Hamartoma, chondroma, sclerosing pneumocytoma
Malignant:
Primary lung cancer: NSCLC, NET / NEC, Salivary gland tumour, pulmonary blastoma
Isolated metastasis
Lymphoid tumour / tumour like condition
Mesenchymal tumour: IMT, synovial sarcoma, SFT, PEComa, primary pulmnary myxoid sarcoma
DDx Mediastinal Tumours
Anterior / Superior Mediastinum
Thymoma and thymic cyst
Germ cell tumours
Thyroid & Parathyroid
Lymphoma
Paraganglioma
Soft tissue: haemangioma, lymphoma
Middle / Central Mediastinum
Pericardial cyst, bronchial cyst, lymphoma
Posterior Mediastinum
Neurogenic tumours incl. BPNST, MPNST, PG, NB
Gastoenteric cysts
Handling of Cardiac Biopsies
Endmyocardial biopsies used for diagnosis of unexplained cardiomyopathy and monitoring of rejection in post-transplant setting
For primary diagnosis at least 4 - 5 biopsies should be take given risk of sampling error and to allow ancillary tests
Require 3 forms of ID and clinical details: medications / drugs, multisystem disease esp. connective tissue disorders, thalssemia, amyloidosis and sarcoidosis, imaging findings (MR and TOE).
Triage tissue - into FFPE for LM, into glutaraldehyde for EM, freeze one piece for DIFL, enzyme analysis or molecular analysis.
LM sections: 3L H&E, Trichrome, CR, PAS, PERLS
Can do bug stains if acute inflammation or granulomas
EM needed for: metabloic / storage disorders e.g. Fabry disease, desmin cardiomyopathy, mitochondrial cardiomyopathy, drugs / toxins e.g anthracycline, paclitaxel.
DDx Paediatric Cardiac Tumours
Cardiac rhabdomyoma (TSC)
Fibroma
Teratoma
Myxoma (Carney complex)
Haemangioma
Also need to consider: thrombus (iatrogenic / device related), vegetation from SBE / RHD, structural anomaly
DDx Adult Cardiac Tumours
BENIGN
Papillary fibroelastoma
Cardiac myxoma (Carney complex)
Adult cellular rhabdomyoma
Cardiac lipoma & cardiac haemangioma
Hamartoma of mature cardiac myocytes
MALIGNANT
Cardiac angiosarcoma
Cardiac leiomyosarcoma
Cardiac UPS
DDx Lymphomas of Mediastinum
Classic Hodgkin Lymphoma
Primary mediastinal large B celll lymphoma
Lymphoblastic lymphoma
Marginal Zone B-cell lymphoma
Other: “gray zone” lymphoma, ALCL, myeloid sarcoma, plasmacytoma, Castleman disease
Mesothelioma - diagnosis, subtypes and grading
Mesothelioma:
Epithelioid, sarcomatoid (incl desmoplastic), biophasic
Mesothelioma in Situ:
Non-resolving effusion nut no no thorascopic /imaging evidence of tumour.
Single layer surface proliferation of cells with loss of BAP1/MTAP by or homozygous deletion of CDKN2A
Diagnosis:
IPX = mesothelial origin and invasion of fat / beyond pleura
Loss of nuclear expression for BAP1 / MTAP
Homozygous deletion of CDKN2a / p16
Grading
Recommended for epithelioid mesothelioma
Nuclear grade based on area of greatest atypia
Nuclear atypia (mild / mod / severe) plus
Mitotic count (per 2mm2) then combine with
Presence or absence of necrosis = low versus high grade
What does this Cardiac Biopsy show?
Giant Cell Myocarditis
What does this Cardiac Biopsy show?
Eosinophilic Myocarditis
What does this Cardiac Biopsy Show?
Amyloid
What does this Cardiac Biopsy show?
Sarcoid
