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30. Hypopigmented CD8+ patch stage mycosis fungoides in an adolescent patient
ABSTRACTS
lymphoma, 40 (21%) follicular centre cell lymphoma, 21 (11%) marginal, seven (4%) T-cell and five (3%) mantle. There were 27 (14%) cases of Hodgkin’s lymphoma. One hundred and five lymphomas were diagnosed in nodal tissue with the most common site being the neck nodes (29%). We encountered 11 cases of CNS lymphoma representing 6% of all lymphoma diagnoses. Core biopsy was performed in only 92 (43%) of cases but was definitively diagnostic of lymphoma in 82 (89%). This high rate of positive core biopsy confirms its role in diagnosis. 29. AUDIT OF FINE NEEDLE ASPIRATION CYTOLOGY ASSESSMENT OF THYROID NODULES Anthony Gill, Carmen Fenech, Jason Chen, Abigail Aktins University of Sydney, and Royal North Shore Hospital, Sydney, NSW, Australia Fine-needle aspiration (FNA) is one of the first line investigations used to triage patients with suspected thyroid pathology. The introduction of the Bethesda Classification System for reporting thyroid cytopathology in 2007 aimed to create universal standards which would contribute to the most appropriate patient management. We audited our experience with this system for the calendar year 2010. We examined 495 thyroid FNA samples from 355 patients. Of the 495 FNAs, 17.4% were category 1 non-diagnostic, 70.7% were category 2 benign, 4.4% were category 3 atypical, 4% were category 4 suspicious for follicular neoplasm, 0.4% were category 5 suspicious for carcinoma and 3% were malignant. All category 5 and 6 cases were found to be malignant at surgery. There was limited follow-up for categories 3 and 4. For category 3, 88% were benign at surgery or category 2 at follow up FNA, with 12% being upgraded to category 4 at repeat FNA (no follow up surgical data available). For the 20 category 4 cases definitive surgical follow-up was only available in eight cases, with five (63%) being benign and three (37%) representing follicular carcinoma. Given that we review most follicular carcinomas resected elsewhere but biopsied in our unit, we suspect that the true rate of malignancy for category 4 aspirates in our unit is 15%. 30. HYPOPIGMENTED CD8R PATCH STAGE MYCOSIS FUNGOIDES IN AN ADOLESCENT PATIENT Mireille Hardie1, S. Prasad Kumarasinghe2, Benjamin A. Wood1 1 PathWest Laboratory Medicine, QEII Medical Centre, and The School of Pathology and Laboratory Medicine, The University of Western Australia, and 2Western Dermatology and Department of Dermatology, Royal Perth Hospital, WA, Australia Mycosis fungoides (MF) represents the most common form of cutaneous T cell lymphoma. The majority of cases represent a neoplastic proliferation of CD4þ/CD8– T cells occurring in middle aged and older adults, often with initial presentation as long standing erythematous patches on non-sun exposed skin. There is, however, a wide range of clinical, morphological and immunophenotypic variation in the presentation of MF. Hypopigmented MF (HyMF) is an uncommon clinical variant which appears to have a predilection for young patients with dark skin, and often shows a CD4–/CD8þ immunophenotype. These characteristics present significant challenges for the pathologist in terms of recognising the possibility of a form of MF and separation from inflammatory dermatoses, particularly the early ‘inflammatory’ phase of vitiligo. Additionally, when the proliferation is recognised as neoplastic, separation from aggressive forms of CD8þ T cell
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lymphoma is critical. We present a case of HyMF in a 16-year-old male showing the CD4–/CD8þ immunophenotype and discuss the differential diagnosis of and clinicopathological approach to these challenging cases. 31. VERRUCOUS POROKERATOSIS OF THE FORESKIN Mireille Hardie, Irene Low, Benjamin A. Wood PathWest Laboratory Medicine, QEII Medical Centre and The School of Pathology and Laboratory Medicine, The University of Western Australia, WA, Australia Porokeratosis is an uncommon genodermatosis, manifest through abnormalities of epidermal maturation and keratinisation, which presents in a number of distinct clinical and pathological forms. Verrucous porokeratosis is a recently described and uncommon porokeratosis variant primarily reported to involve the gluteal cleft. This variant shows prominent digitate epidermal hyperplasia and confluence of cornoid lamellae, histopathological features which are not generally associated with other described forms of porokeratosis. We present the first case of verrucous porokeratosis described on the penis. Review of the patient’s history identified a lesion of verrucous porokeratosis of the buttock incorrectly diagnosed as verruca vulgaris 7 years previously before more widespread porokeratotic lesions were recognised. This case highlights that clinical and pathological familiarity with verrucous porokeratosis is critical to avoid misdiagnosis as a human papilloma virus induced lesion, an interpretation which may be associated with unnecessary social stigma in the genitogluteal region. Although development of squamous cell carcinoma has not been reported in verrucous porokeratosis to date, it is a well recognised complication of other forms of porokeratosis and clinical follow up would seem appropriate. 32. PRIMARY SYNOVIAL SARCOMA OF THE MEDIASTINUM Jennifer Kim1, Rooshdiya Karim1, Hae Won Kim2, Christina Selinger1, Sandra O’Toole1, Annabelle Mahar 1, Richard Scolyer1, Stan McCarthy1, James Kench1 1 Department of Tissue Pathology and Diagnostic Oncology, and 2 Department of Radiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia Background: Synovial sarcoma is a malignant soft tissue neoplasm which predominantly occurs in the extremities of adolescents and young adults. However, it is extremely rare in the mediastinum. Case report: A 30-year-old man with an unremarkable past medical history presented with 2 months history of left posterior chest wall pain, malaise and exertional dyspnoea. The CT scan showed a left-sided large mediastinal mass displacing the left kidney anteriorly. Clinically, a germ cell tumour or thymoma was suspected. A CT-guided fine needle aspiration biopsy showed relatively uniform plump spindle cells arranged in loosely cohesive tissue fragments, many of which contain capillary cores. The cells had bipolar pale cytoplasm, ovoid nuclei and small nucleoli. The diagnosis of spindle cell neoplasm was favoured. The core biopsy showed a spindle cell tumour with hyperchromatic nuclei and inconspicuous nucleoli. The cells were uniform with scant mitotic figures. The tumour cells were positive for EMA, CD99 and BCL-2. Staining for keratin, CD31/CD34, CD3, CD20, SMA, P63, S100, HMB45 were negative. FISH using the SS18
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.
lymphoma, 40 (21%) follicular centre cell lymphoma, 21 (11%) marginal, seven (4%) T-cell and five (3%) mantle. There were 27 (14%) cases of Hodgkin’s lymphoma. One hundred and five lymphomas were diagnosed in nodal tissue with the most common site being the neck nodes (29%). We encountered 11 cases of CNS lymphoma representing 6% of all lymphoma diagnoses. Core biopsy was performed in only 92 (43%) of cases but was definitively diagnostic of lymphoma in 82 (89%). This high rate of positive core biopsy confirms its role in diagnosis. 29. AUDIT OF FINE NEEDLE ASPIRATION CYTOLOGY ASSESSMENT OF THYROID NODULES Anthony Gill, Carmen Fenech, Jason Chen, Abigail Aktins University of Sydney, and Royal North Shore Hospital, Sydney, NSW, Australia Fine-needle aspiration (FNA) is one of the first line investigations used to triage patients with suspected thyroid pathology. The introduction of the Bethesda Classification System for reporting thyroid cytopathology in 2007 aimed to create universal standards which would contribute to the most appropriate patient management. We audited our experience with this system for the calendar year 2010. We examined 495 thyroid FNA samples from 355 patients. Of the 495 FNAs, 17.4% were category 1 non-diagnostic, 70.7% were category 2 benign, 4.4% were category 3 atypical, 4% were category 4 suspicious for follicular neoplasm, 0.4% were category 5 suspicious for carcinoma and 3% were malignant. All category 5 and 6 cases were found to be malignant at surgery. There was limited follow-up for categories 3 and 4. For category 3, 88% were benign at surgery or category 2 at follow up FNA, with 12% being upgraded to category 4 at repeat FNA (no follow up surgical data available). For the 20 category 4 cases definitive surgical follow-up was only available in eight cases, with five (63%) being benign and three (37%) representing follicular carcinoma. Given that we review most follicular carcinomas resected elsewhere but biopsied in our unit, we suspect that the true rate of malignancy for category 4 aspirates in our unit is 15%. 30. HYPOPIGMENTED CD8R PATCH STAGE MYCOSIS FUNGOIDES IN AN ADOLESCENT PATIENT Mireille Hardie1, S. Prasad Kumarasinghe2, Benjamin A. Wood1 1 PathWest Laboratory Medicine, QEII Medical Centre, and The School of Pathology and Laboratory Medicine, The University of Western Australia, and 2Western Dermatology and Department of Dermatology, Royal Perth Hospital, WA, Australia Mycosis fungoides (MF) represents the most common form of cutaneous T cell lymphoma. The majority of cases represent a neoplastic proliferation of CD4þ/CD8– T cells occurring in middle aged and older adults, often with initial presentation as long standing erythematous patches on non-sun exposed skin. There is, however, a wide range of clinical, morphological and immunophenotypic variation in the presentation of MF. Hypopigmented MF (HyMF) is an uncommon clinical variant which appears to have a predilection for young patients with dark skin, and often shows a CD4–/CD8þ immunophenotype. These characteristics present significant challenges for the pathologist in terms of recognising the possibility of a form of MF and separation from inflammatory dermatoses, particularly the early ‘inflammatory’ phase of vitiligo. Additionally, when the proliferation is recognised as neoplastic, separation from aggressive forms of CD8þ T cell
S113
lymphoma is critical. We present a case of HyMF in a 16-year-old male showing the CD4–/CD8þ immunophenotype and discuss the differential diagnosis of and clinicopathological approach to these challenging cases. 31. VERRUCOUS POROKERATOSIS OF THE FORESKIN Mireille Hardie, Irene Low, Benjamin A. Wood PathWest Laboratory Medicine, QEII Medical Centre and The School of Pathology and Laboratory Medicine, The University of Western Australia, WA, Australia Porokeratosis is an uncommon genodermatosis, manifest through abnormalities of epidermal maturation and keratinisation, which presents in a number of distinct clinical and pathological forms. Verrucous porokeratosis is a recently described and uncommon porokeratosis variant primarily reported to involve the gluteal cleft. This variant shows prominent digitate epidermal hyperplasia and confluence of cornoid lamellae, histopathological features which are not generally associated with other described forms of porokeratosis. We present the first case of verrucous porokeratosis described on the penis. Review of the patient’s history identified a lesion of verrucous porokeratosis of the buttock incorrectly diagnosed as verruca vulgaris 7 years previously before more widespread porokeratotic lesions were recognised. This case highlights that clinical and pathological familiarity with verrucous porokeratosis is critical to avoid misdiagnosis as a human papilloma virus induced lesion, an interpretation which may be associated with unnecessary social stigma in the genitogluteal region. Although development of squamous cell carcinoma has not been reported in verrucous porokeratosis to date, it is a well recognised complication of other forms of porokeratosis and clinical follow up would seem appropriate. 32. PRIMARY SYNOVIAL SARCOMA OF THE MEDIASTINUM Jennifer Kim1, Rooshdiya Karim1, Hae Won Kim2, Christina Selinger1, Sandra O’Toole1, Annabelle Mahar 1, Richard Scolyer1, Stan McCarthy1, James Kench1 1 Department of Tissue Pathology and Diagnostic Oncology, and 2 Department of Radiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia Background: Synovial sarcoma is a malignant soft tissue neoplasm which predominantly occurs in the extremities of adolescents and young adults. However, it is extremely rare in the mediastinum. Case report: A 30-year-old man with an unremarkable past medical history presented with 2 months history of left posterior chest wall pain, malaise and exertional dyspnoea. The CT scan showed a left-sided large mediastinal mass displacing the left kidney anteriorly. Clinically, a germ cell tumour or thymoma was suspected. A CT-guided fine needle aspiration biopsy showed relatively uniform plump spindle cells arranged in loosely cohesive tissue fragments, many of which contain capillary cores. The cells had bipolar pale cytoplasm, ovoid nuclei and small nucleoli. The diagnosis of spindle cell neoplasm was favoured. The core biopsy showed a spindle cell tumour with hyperchromatic nuclei and inconspicuous nucleoli. The cells were uniform with scant mitotic figures. The tumour cells were positive for EMA, CD99 and BCL-2. Staining for keratin, CD31/CD34, CD3, CD20, SMA, P63, S100, HMB45 were negative. FISH using the SS18
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.