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Cardiomyopathies: diagnosis and significance
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PATHOLOGY UPDATE 2009 ABSTRACT PUBLICATION
3 Department of Oral Pathology, University of the Western Cape, Cape Town, South Africa This paper will report on two similar cases of odontogenic pathology. Case 1 was a 58-year-old female with a radiolucency in the right posterior mandible. Teeth in the adjacent area were reported as being non-vital. Case 2 was a 16-year-old male with a provisional clinical diagnosis of a dentigerous cyst associated with the unerupted maxillary right third molar. Histopathological examination in each case showed a cystic space lined by epithelium with typical features of an odontogenic keratocyst. However, numerous islands of odontogenic epithelium were present in the cyst wall immediately below the lining epithelium. These islands resembled an ameloblastoma. The epithelial proliferation was confined to the zone immediately beneath the lining epithelium. Calretinin staining was negative. In case 1 there were large inclusion bodies/keratohyaline granules within the epithelium which raised the possibility of the presence of human papillomavirus. In case 2 Rushton hyaline bodies were seen. The differential diagnosis was felt to lie between an odontogenic keratocyst with unusual epithelial proliferation and an ameloblastoma with cystic change. Malignant transformation of an odontogenic cyst was also considered. Ultimately each case was signed out as an odontogenic keratocyst with unusual epithelial proliferation within the wall.
SALIVARY DUCT CARCINOMA CASES
REPORT OF TWO
Hedley Coleman1, M Bilous1, C E Palme2, G Morgan2 1 Department of Tissue Pathology, ICPMR, and the University of Sydney, Westmead Hospital, Sydney 2 Department of Surgery, Westmead Hospital, SWAHS, Sydney, NSW, Australia Background: Salivary duct carcinoma (SDC) is a distinctive salivary gland neoplasm which bears a histological similarity to ductal breast carcinoma including intraductal and invasive components. It was first described by Kleinsasser et al. in 1968 and has recently been included in the WHO Classification of Head and Neck Tumours (2005). Method: Two cases of SDC are reported with their clinical and immunohistochemical findings. Results: The tumour cells showed a characteristic immunophenotype with positivity for Androgen receptors (AR). There was no reaction with oestrogen or progesterone receptors. HER-2/neu 3 staining was identified by immunohistochemistry together with gene amplification (SISH). Conclusion: The strong and diffuse expression of AR and HER-2/ neu overexpression lends further support to the role that antiandrogen and Herceptin therapy may have in patients with disseminated SDC.
RENAL CELL CARCINOMA METASTASISING TO THE TONGUE Jane Dahlstrom ACT Pathology and Anatomical Pathology, Australian National University Medical School, The Canberra Hospital, ACT, Australia A 70-year-old male presented to his general practitioner after he noticed an ulcerated lump on the right anterior aspect of his tongue. Eighteen months prior to this presentation a total nephectomy had been performed for the management of a Fuhrman Grade 2 conventional clear cell renal cell carcinoma of the
lower pole of the right kidney. The patient was known to have widespread metastases at the time of this presentation. On examination the nodule measured 10 mm across and a metastasis was suspected. In view of the clinical findings, and discomfort to the patient, an excisional biopsy was performed. Light microscopy showed features of metastatic renal cell carcinoma associated with an ulcerated overlying pyogenic granuloma-like lesion. On immunohistochemistry, the tumour cells expressed EMA, vimentin and CD10 with similar morphology to the primary renal carcinoma. Tongue metastasis of renal cell carcinoma is very rare but usually is a manifestation of wide spread disease. The tumour may masquerade clinically and microscopically as a pyogenic granuloma. Metastasis to the tongue may also be the initial site of presentation of renal cell carcinoma and so should be considered in the microscopic differential diagnosis of a clear cell malignancy in the tongue.
LONG-STANDING ULCERATIVE LESION AT THE JUNCTION OF THE HARD AND SOFT PALATE Richard Logan1,2,3, Philip Pirgousis3 1 Oral Pathology, School of Dentistry, The University of Adelaide, Australia 2 Division of Surgical Pathology, SA Pathology, Adelaide, Australia 3 Oral and Maxillofacial Surgery Unit, Adelaide Dental Hospital, Australia An 80-year-old male was referred to the Oral and Maxillofacial Surgery Unit of the Adelaide Dental Hospital with regard to longstanding palatal ulceration. The clinical history described a nonhealing ulcer at the junction of the right hard and soft palate. According to the patient, the ulcer had occurred periodically over a 2 year period. The lesion was biopsied and tissue submitted for histopathology. Histological examination of the soft tissue demonstrated the presence of an invasive neoplastic infiltrate with small cell morphology. The cells were arranged in irregular nests and exhibited brisk mitotic activity. The overlying epithelium demonstrated reactive atypia. The tumour involved and infiltrated minor salivary gland tissue. Immunohistochemically, the tumour demonstrated positive staining for CD56, cytokeratin 20, AE1/3, Cam 5.2 and chromogranin. These features were considered to be in keeping with a small cell carcinoma of salivary gland origin. The clinical behaviour, pathology and management of salivary gland small cell carcinomas will be reviewed and discussed.
CARDIOMYOPATHIES: DIAGNOSIS AND SIGNIFICANCE Jagdish Butany University of Toronto and Toronto General Hospital, Toronto, Canada The cardiomyopathies are an important yet heterogenous group of diseases, the understanding and significance of which is somewhat limited in the minds of the public and of physicians. Their significance lies not in their incidence, which is relatively rare, especially that of the familial cardiomyopathies, but in their impact on the individuals with the disease and those who succumb to them. It is equally important for the pathologists to be aware and wary of these diseases, since the impact of the diagnosis on the survivors amongst the immediate family of the deceased can be quite significant, mentally as well as medically. These diagnoses should not be made lightly but only after a thorough and detailed examination of the heart using appropriate criteria. This case based session will cover the common cardiomyopathies,
PATHOLOGY UPDATE 2009 ABSTRACT PUBLICATION
encompassing the current understanding of their pathogenesis, their major morphological/diagnostic features and their complications. The major significance of the cardiomyopathies lies in their impact on the young and their families, especially with regard to sudden unexpected cardiac death. A pathologist performing autopsies must be aware of their morphological features and of their significance. (This session will be of benefit to residents and all practicing anatomical pathologists, and especially for those doing autopsies.)
PERINATAL PATHOLOGY Ona Faye-Petersen Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, United States The perinatal autopsy/previable feotal examination presents special challenges to general pathologists and trainees, but the presence of foetal structural remnants, changing developmental features, small organ sizes, and potential for encountering complex anomalies may also be daunting to specially trained paediatric pathologists. This workshop will present the highlights of: (1) normal previable and viable fetal development, (2) how to assess gestational age and duration of intrauterine retention following fetal death, (3) differences and similarities between perinatal and adult autopsy examinations, (4) anomalous features of select common syndromes, associations and sequences, and (5) the use of the placenta as a critical supplement for determining cause of death in the stillborn or briefly viable neonate. The tools acquired in this workshop will enable pathologists to approach the perinatal pathological examination with informed confidence and ability to interpret and use reference ranges for foetal/neonatal anthropometry and organ weight.
THE FUTURE OF GYNECOLOGICAL CYTOLOGY IN THE MOLECULAR ERA Mark H Stoler Pathology and Gynecology, University of Virginia Health System, United States The Pap smear, the best example of a cancer-screening test, leads to a 7590% reduction in the incidence of cervical cancer. Why should countries with successful cervical cancer screening programs change methods? The Pap has long been recognised for its modest sensitivity and performs best when disease prevalence is high. The impact of a lowering prevalence of disease makes evolution of the cervical cancer screening system a mathematical necessity. As the prevalence of CIN III and invasive cancer drops in highly screened populations, even optimised Pap smears using liquid based cytology combined with automation may underperform more sensitive screening methods. In addition, morphological screening may suffer in specificity as well as sensitivity. More slides will be less likely to have significant cytological abnormality and the long interval between significantly abnormal slides will lend itself to an increase in false positives. These established trends will be impacted dramatically by the application of effective prophylactic human papillomavirus (HPV) vaccines. The solution to this mathematical conundrum is the application of more sensitive screening tests and molecular diagnostics for HPV DNA as the most likely candidate to succeed the Pap. The results of recent randomised controlled trials will be reviewed to support this thesis.
11
CARDIOVASCULAR SURGICAL PATHOLOGY Jagdish Butany University of Toronto and Toronto General Hospital, Toronto, Canada Heart disease comprises a major component of medical practice, and increasingly virtually everywhere in the world cardiovascular surgery in its many forms plays a significant role in the management of patients with heart disease, whether it be valvular, myocardial or coronary. Increasingly, patients undergo heart transplantation, a procedure limited only by the availability of donor hearts. The gold standard for monitoring the graft heart is follow-up endomyocardial biopsies. The appropriate interpretation of an endomyocardial biopsy therefore comprises a very critical and significant component of the management of patients post heart transplant. The appropriate examination, diagnosis and understanding of the pathology of these tissues provides answers for the patient and for the future understanding of heart disease. This case based session will provide an approach to and an understanding of endomyocardial biopsies, diagnostic and therapeutic (monitoring heart transplant); the examination of explanted cardiac devices, be they valve replacements, stents, ventricular assist devices, native heart valves, explant hearts, myectomies, cardiac tumours and other cardiac surgical tissues. (This session will be of benefit to residents and all practicing anatomical pathologists.)
HINTS, TIPS AND CLUES IN DERMATOPATHOLOGY Trevor W Beer, Minh Lam Cutaneous Pathology, Nedlands, Western Australia There are a number of excellent dermatopathology texts available and a plethora of journals. However, day to day problems frequently arise for which the traditional textbook approach is lacking. In this workshop, we use cases from daily practice to illustrate diagnostic approaches and techniques and to highlight some valuable hints, tips and clues to the diagnostic process. Cases for discussion are available as virtual images on the precirculated DVD. In addition, practical details of the methods presented will be available on the post-meeting CD. Topics covered include: . Three benign processes readily misdiagnosed as malignancy. . How do you immunostain highly pigmented lesions? . Heart sink biopsies what do you do when it all looks normal? . Why we don’t use Congo red. . When and how your dermatologist should biopsy alopecia.
PATHOLOGY RESIDENT TRAINING IN THE UNITED STATES: A COLLEGE OF AMERICAN PATHOLOGISTS’ PERSPECTIVE Michael L Talbert The University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States The practice of pathology is rapidly changing. Advances in science, progress in therapeutics and novel technological applications create both new opportunities and new challenges for pathologists. Economic realities drive new practice models and encourage attention to quality and integration of care delivery. The trainees of today must be well versed in the science, skilled in the
PATHOLOGY UPDATE 2009 ABSTRACT PUBLICATION
3 Department of Oral Pathology, University of the Western Cape, Cape Town, South Africa This paper will report on two similar cases of odontogenic pathology. Case 1 was a 58-year-old female with a radiolucency in the right posterior mandible. Teeth in the adjacent area were reported as being non-vital. Case 2 was a 16-year-old male with a provisional clinical diagnosis of a dentigerous cyst associated with the unerupted maxillary right third molar. Histopathological examination in each case showed a cystic space lined by epithelium with typical features of an odontogenic keratocyst. However, numerous islands of odontogenic epithelium were present in the cyst wall immediately below the lining epithelium. These islands resembled an ameloblastoma. The epithelial proliferation was confined to the zone immediately beneath the lining epithelium. Calretinin staining was negative. In case 1 there were large inclusion bodies/keratohyaline granules within the epithelium which raised the possibility of the presence of human papillomavirus. In case 2 Rushton hyaline bodies were seen. The differential diagnosis was felt to lie between an odontogenic keratocyst with unusual epithelial proliferation and an ameloblastoma with cystic change. Malignant transformation of an odontogenic cyst was also considered. Ultimately each case was signed out as an odontogenic keratocyst with unusual epithelial proliferation within the wall.
SALIVARY DUCT CARCINOMA CASES
REPORT OF TWO
Hedley Coleman1, M Bilous1, C E Palme2, G Morgan2 1 Department of Tissue Pathology, ICPMR, and the University of Sydney, Westmead Hospital, Sydney 2 Department of Surgery, Westmead Hospital, SWAHS, Sydney, NSW, Australia Background: Salivary duct carcinoma (SDC) is a distinctive salivary gland neoplasm which bears a histological similarity to ductal breast carcinoma including intraductal and invasive components. It was first described by Kleinsasser et al. in 1968 and has recently been included in the WHO Classification of Head and Neck Tumours (2005). Method: Two cases of SDC are reported with their clinical and immunohistochemical findings. Results: The tumour cells showed a characteristic immunophenotype with positivity for Androgen receptors (AR). There was no reaction with oestrogen or progesterone receptors. HER-2/neu 3 staining was identified by immunohistochemistry together with gene amplification (SISH). Conclusion: The strong and diffuse expression of AR and HER-2/ neu overexpression lends further support to the role that antiandrogen and Herceptin therapy may have in patients with disseminated SDC.
RENAL CELL CARCINOMA METASTASISING TO THE TONGUE Jane Dahlstrom ACT Pathology and Anatomical Pathology, Australian National University Medical School, The Canberra Hospital, ACT, Australia A 70-year-old male presented to his general practitioner after he noticed an ulcerated lump on the right anterior aspect of his tongue. Eighteen months prior to this presentation a total nephectomy had been performed for the management of a Fuhrman Grade 2 conventional clear cell renal cell carcinoma of the
lower pole of the right kidney. The patient was known to have widespread metastases at the time of this presentation. On examination the nodule measured 10 mm across and a metastasis was suspected. In view of the clinical findings, and discomfort to the patient, an excisional biopsy was performed. Light microscopy showed features of metastatic renal cell carcinoma associated with an ulcerated overlying pyogenic granuloma-like lesion. On immunohistochemistry, the tumour cells expressed EMA, vimentin and CD10 with similar morphology to the primary renal carcinoma. Tongue metastasis of renal cell carcinoma is very rare but usually is a manifestation of wide spread disease. The tumour may masquerade clinically and microscopically as a pyogenic granuloma. Metastasis to the tongue may also be the initial site of presentation of renal cell carcinoma and so should be considered in the microscopic differential diagnosis of a clear cell malignancy in the tongue.
LONG-STANDING ULCERATIVE LESION AT THE JUNCTION OF THE HARD AND SOFT PALATE Richard Logan1,2,3, Philip Pirgousis3 1 Oral Pathology, School of Dentistry, The University of Adelaide, Australia 2 Division of Surgical Pathology, SA Pathology, Adelaide, Australia 3 Oral and Maxillofacial Surgery Unit, Adelaide Dental Hospital, Australia An 80-year-old male was referred to the Oral and Maxillofacial Surgery Unit of the Adelaide Dental Hospital with regard to longstanding palatal ulceration. The clinical history described a nonhealing ulcer at the junction of the right hard and soft palate. According to the patient, the ulcer had occurred periodically over a 2 year period. The lesion was biopsied and tissue submitted for histopathology. Histological examination of the soft tissue demonstrated the presence of an invasive neoplastic infiltrate with small cell morphology. The cells were arranged in irregular nests and exhibited brisk mitotic activity. The overlying epithelium demonstrated reactive atypia. The tumour involved and infiltrated minor salivary gland tissue. Immunohistochemically, the tumour demonstrated positive staining for CD56, cytokeratin 20, AE1/3, Cam 5.2 and chromogranin. These features were considered to be in keeping with a small cell carcinoma of salivary gland origin. The clinical behaviour, pathology and management of salivary gland small cell carcinomas will be reviewed and discussed.
CARDIOMYOPATHIES: DIAGNOSIS AND SIGNIFICANCE Jagdish Butany University of Toronto and Toronto General Hospital, Toronto, Canada The cardiomyopathies are an important yet heterogenous group of diseases, the understanding and significance of which is somewhat limited in the minds of the public and of physicians. Their significance lies not in their incidence, which is relatively rare, especially that of the familial cardiomyopathies, but in their impact on the individuals with the disease and those who succumb to them. It is equally important for the pathologists to be aware and wary of these diseases, since the impact of the diagnosis on the survivors amongst the immediate family of the deceased can be quite significant, mentally as well as medically. These diagnoses should not be made lightly but only after a thorough and detailed examination of the heart using appropriate criteria. This case based session will cover the common cardiomyopathies,
PATHOLOGY UPDATE 2009 ABSTRACT PUBLICATION
encompassing the current understanding of their pathogenesis, their major morphological/diagnostic features and their complications. The major significance of the cardiomyopathies lies in their impact on the young and their families, especially with regard to sudden unexpected cardiac death. A pathologist performing autopsies must be aware of their morphological features and of their significance. (This session will be of benefit to residents and all practicing anatomical pathologists, and especially for those doing autopsies.)
PERINATAL PATHOLOGY Ona Faye-Petersen Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, United States The perinatal autopsy/previable feotal examination presents special challenges to general pathologists and trainees, but the presence of foetal structural remnants, changing developmental features, small organ sizes, and potential for encountering complex anomalies may also be daunting to specially trained paediatric pathologists. This workshop will present the highlights of: (1) normal previable and viable fetal development, (2) how to assess gestational age and duration of intrauterine retention following fetal death, (3) differences and similarities between perinatal and adult autopsy examinations, (4) anomalous features of select common syndromes, associations and sequences, and (5) the use of the placenta as a critical supplement for determining cause of death in the stillborn or briefly viable neonate. The tools acquired in this workshop will enable pathologists to approach the perinatal pathological examination with informed confidence and ability to interpret and use reference ranges for foetal/neonatal anthropometry and organ weight.
THE FUTURE OF GYNECOLOGICAL CYTOLOGY IN THE MOLECULAR ERA Mark H Stoler Pathology and Gynecology, University of Virginia Health System, United States The Pap smear, the best example of a cancer-screening test, leads to a 7590% reduction in the incidence of cervical cancer. Why should countries with successful cervical cancer screening programs change methods? The Pap has long been recognised for its modest sensitivity and performs best when disease prevalence is high. The impact of a lowering prevalence of disease makes evolution of the cervical cancer screening system a mathematical necessity. As the prevalence of CIN III and invasive cancer drops in highly screened populations, even optimised Pap smears using liquid based cytology combined with automation may underperform more sensitive screening methods. In addition, morphological screening may suffer in specificity as well as sensitivity. More slides will be less likely to have significant cytological abnormality and the long interval between significantly abnormal slides will lend itself to an increase in false positives. These established trends will be impacted dramatically by the application of effective prophylactic human papillomavirus (HPV) vaccines. The solution to this mathematical conundrum is the application of more sensitive screening tests and molecular diagnostics for HPV DNA as the most likely candidate to succeed the Pap. The results of recent randomised controlled trials will be reviewed to support this thesis.
11
CARDIOVASCULAR SURGICAL PATHOLOGY Jagdish Butany University of Toronto and Toronto General Hospital, Toronto, Canada Heart disease comprises a major component of medical practice, and increasingly virtually everywhere in the world cardiovascular surgery in its many forms plays a significant role in the management of patients with heart disease, whether it be valvular, myocardial or coronary. Increasingly, patients undergo heart transplantation, a procedure limited only by the availability of donor hearts. The gold standard for monitoring the graft heart is follow-up endomyocardial biopsies. The appropriate interpretation of an endomyocardial biopsy therefore comprises a very critical and significant component of the management of patients post heart transplant. The appropriate examination, diagnosis and understanding of the pathology of these tissues provides answers for the patient and for the future understanding of heart disease. This case based session will provide an approach to and an understanding of endomyocardial biopsies, diagnostic and therapeutic (monitoring heart transplant); the examination of explanted cardiac devices, be they valve replacements, stents, ventricular assist devices, native heart valves, explant hearts, myectomies, cardiac tumours and other cardiac surgical tissues. (This session will be of benefit to residents and all practicing anatomical pathologists.)
HINTS, TIPS AND CLUES IN DERMATOPATHOLOGY Trevor W Beer, Minh Lam Cutaneous Pathology, Nedlands, Western Australia There are a number of excellent dermatopathology texts available and a plethora of journals. However, day to day problems frequently arise for which the traditional textbook approach is lacking. In this workshop, we use cases from daily practice to illustrate diagnostic approaches and techniques and to highlight some valuable hints, tips and clues to the diagnostic process. Cases for discussion are available as virtual images on the precirculated DVD. In addition, practical details of the methods presented will be available on the post-meeting CD. Topics covered include: . Three benign processes readily misdiagnosed as malignancy. . How do you immunostain highly pigmented lesions? . Heart sink biopsies what do you do when it all looks normal? . Why we don’t use Congo red. . When and how your dermatologist should biopsy alopecia.
PATHOLOGY RESIDENT TRAINING IN THE UNITED STATES: A COLLEGE OF AMERICAN PATHOLOGISTS’ PERSPECTIVE Michael L Talbert The University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States The practice of pathology is rapidly changing. Advances in science, progress in therapeutics and novel technological applications create both new opportunities and new challenges for pathologists. Economic realities drive new practice models and encourage attention to quality and integration of care delivery. The trainees of today must be well versed in the science, skilled in the