Desmoplastic melanoma, a common missed diagnosis.

Introduction:

Although desmoplastic melanoma represents less than 2 percent of all melanomas, it's frequently misdiagnosed, due to a lack of distinctive clinical presentation features. Histologic diagnosis is rarely straightforward either.

Patients are often middle age-to-elderly and present with the tumor most often on the head and neck region. The lesion may resemble a scar as it is often a hard nodule or plaque.
Pigmentation is variable but often absent. The tumor has ill-defined margins and is very infiltrative, making local control difficult. Sentinel lymph node excision is routinely performed but rarely positive.

Histology :
The histology can also masquerade as a scar . The epidermis is often atrophic and may or may not have a precursor (in situ) lesion. Characteristically, the tumor is in the dermis as spindled melanocytes resembling fibroblasts.Often, there is an edematous or desmoplastic stroma with
scattered lymphoid aggregates. Perineural invasion is common.In about one third of the lesions, there are foci of epithelioid or conventional melanoma.

S-100 and HMB45 immunohistochemical stains can help differentiate tumor from scar.
At low power, there is a fibrotic lesion in the dermis with scattered lymphoid aggregates.

The lesion is paucicellular, but there is cellular atypia .

Reporting of the histologic subtype of melanoma is common practice, but it is unclear what impact, if any, it has on management decisions. One possible exception is desmoplastic melanoma, a distinct subtype with a unique biologic behavior. It is now recognized that desmoplastic melanomas present with greater tumor thickness (Breslow level) than their conventional counterparts but fail to demonstrate a corresponding higher sentinel lymph node involvement or higher mortality.

Some authors have further subdivided desmoplastic melanomas into "pure" and "mixed" forms. Pure (primarily fibrotic) and mixed varieties, which include features common to conventional melanoma and desmoplastic areas. As per these recent studies only 1% of pure desmoplastic melanomas metastasized to regional lymph nodes compared to 10% with mixed histology.

References:
1. Attis MG, Burchette JL, Selim MA, et al. Differential expression of N-cadherin distinguishes a subset metastasizing desmoplastic melanoma.
2. Davison JM, Rosenbaum E, Barrett TL, et al. Absence of V599E BRAF mutations in desmoplastic melanomas. Cancer. 2005 103:788.
3. Hawkins WG, Busam KJ, Ben-Porat L, et al. Desmoplastic melanoma:a pathologically and clinically distinct form of melanoma. Ann Surg Oncol. 2005 12:207.

Dysplasia in Inflammatory Bowel Disease

As we all know, chronic inflammatory bowel disease (IBD) presents a risk for dysplasia and subsequent malignancy in patients with long standing disease.

The risk for adenocarcinoma increases with a number of factors including

• 
  
  the linear extent of disease within the bowel,
• 
  
  early age at onset of disease,
• 
  
  severity of disease and duration of disease.

The pathologic reporting of endoscopic biopsy specimens with inflammatory bowel disease must convey the information the clinician needs in a clear and consistent manner in order to properly manage the patient's disease.

Every biopsy report should, of course, give an assessment of the disease activity and distribution. In addition, the pathologist must render an opinion on the presence or absence of dysplasia. The "second line" diagnosis must reflect one of three choices regarding dysplasia in the biopsy:

1. Negative for dysplasia

2. Indefinite for dysplasia

3. Positive for dysplasia

• Low grade
• High grade

Agreeing on the terminology is relatively easy. Agreeing on the morphologic presence or absence of dysplasia is another issue.

Studies have shown poor interobserver reproducibility with regard to recognizing and diagnosing dysplasia. Low grade dysplasia (LGD), as one might guess, suffers from the worst interobserver variability.

The more marked the cytologic changes (high grade dysplasia) the easier it is to recognize and agree upon amongst pathologists.

This variability is one reason that many suggest surveillance for LGD. The histologic parameters which define dysplasia in the colon are consistent regardless of the subtype of IBD - Crohn's colitis or ulcerative colitis.

Negative for dysplasia

The lack of dysplasia in a chronic IBD biopsy is stated as "negative for dysplasia". That phrase should be included in biopsies that are completely normal or indistinguishable from non-IBD biopsies. This could be found in biopsies obtained from an area of the colon that is not affected by the disease or in an area that is completely quiescent perhaps from treatment.

Reactive changes that can and areseen in colitis biopsies are also included in the "negative for dysplasia" category. Some refer to such changes as "baseline atypia"; regardless, that limited spectrum is devoid of dysplasia and falls under the heading of "negative".

Indefinite for dysplasia

This category sometimes suffers from a lack of respect or credibility; however, it is a defined, accepted and even required category in properlyinterpreting dysplasia in IBD.

It is not a crutch upon which uncertain and weak willed pathologists lean. The changes that are included in the indefinite category must be recognized as such lest one either overcalls or undercalls dysplasia when it cannot be unequivocally determined whether it is present or absent. One such example is when dysplasia shows partial surface maturation. That is, the involvement of the surface epithelium by dysplastic change and not just the basal, proliferating portions of crypts is required to make a diagnosis of dysplasia. If the surface is partially involved or shows incomplete maturation then indefinite is the proper designation.

A biopsy that shows marked acute inflammation, erosion or ulceration that has cytologic changes that absent the inflammation would be called dysplastic must be designated as indefinite. This use is intended to recognize that the presence of inflammation makes diagnosing dysplasia with certainty nearly impossible.

Positive for dysplasia- low and high grade .

If there is flat dysplasia present in a biopsy, then one of the above choices (low grade or high grade) ought to appear in the report.

Criterias:

Low grade dysplasia: basally oriented nuclei; mild nuclear enlargement, nuclear crowding and hyperchromasia; decreased intracellular mucin High grade dysplasia: prominent nuclear stratification (compared to low grade) with many nuclei in luminal half of cell; more significant hyperchromasia and pleomorphism; may have marked architectural distortion with a villous or nodular growth pattern resembling adenoma or with cribriforming
The best tool that a pathologist has in effectively interpreting IBD biopsies for dysplasia is the most basic one - the simple hematoxylin and eosin stained tissue section. Ancillary tests such as immunohistochemistry have not proven as effective as the simple histologic evaluation of the H&E stain.

Experience of the pathologist in seeing and appropriately interpreting dysplasia in IBD biopsies is of critical importance.

Proper written and verbal communication between the gastrointestinal pathologist and the endoscopist is essential in going from the correct interpretation to the proper clinical course.

This is of paramount importance in interpreting polypoid dysplasia and distinguishing between a sporadic adenoma and a dysplasia associated lesion or mass (DALM).

SELECTED REFERENCES

• Riddell RH, Goldman H, Ransohoff DF, et al: Dysplasia in inflammatory bowel disease: Standardized classification with provisional applications. Hum Pathol 14:931-968, 1983.
• Bernstein CN, Blanchard JF, Kliewer E, et al: Cancer risk in patients with inflammatory bowel disease: A population-based study. Cancer 91: 854-862, 2001.
• Odze RD, Goldblum JR, Noffsinger A: Interobserver variability in the diagnosis of ulcerative colitis-associated dysplasia by telepathology. ModPathol 15:379-386, 2000.

Making Sure Your Lab Reports Are Easy to Understand

A portion of clinical error results from the misinterpretation of laboratory data. Powsner et al reported that surgeons misunderstood 30% of pathology reports.
Whether one communicates test results electronically, by fax, or on paper, one should periodically review the content and layout of the reports to make sure they are as useful as possible. Are the clinicians and caregivers who receive the reports getting the information they need to treat the patient? Is the information clear, accurate, and laid out in such a way that the readers don’t have to struggle to comprehend the data?

Easy Places to Start
Periodically (at a minimum, annually) review all versions of your reports, with the goal of increasing their quality, accuracy, and interpretability. Also review your reports whenever there has been a readability complaint or after a change in testing methodology.
• Make the font size large enough. The report should be quickly and easily readable, at arm’s length, in imperfect lighting, by someone wearing bifocals. The smaller the font, the greater the likelihood of misreading the value.
• Perform legibility tests:
o Fax a sample of your reports to yourself. Are the numbers and text small and fuzzy or are they clear and legible? To simulate what your customers may see, repeat the test using the fax you just received.
o If your reports are being read via a hospital or practice management computer system, verify that your reports display appropriately and legibly on the systems the physicians are using to read the reports.
• Check for complete patient information, including full name, date of birth, and gender.
• Check for specimen source/type, reference ranges or target ranges, and flags ( if indicated).
• Check that Medical Director, facility name, and contact details are on every page of every report.
• Verify any calculated results.
• Check for coding and billing information and any pay-for-performance indicators—e.g., PQRI codes.
• Review the clarity of the interpretation and any comments—e.g., are interpretations clearly associated with the related result?
• Check for reference to prior results, if any. If the result is a critical value, make sure the report includes documentation of appropriate communication—e.g., who notified whom? When? How?

Digging Deeper
There is a lot at stake in one simple lab report. In one study, surgeons misunderstood pathologists’ reports 30% of the time (Powsner). These additional steps can help improve the usability of your reports:
• Standardize the “look and feel” of your results to make them easier to interpret. Putting the same information in the same place, time after time, trains your readers to locate what they are looking for.
• Don’t crowd the data on the page; use sufficient white space to separate columns and lines of numbers.
• All the text should be a good distance from the margins, so no text gets cut off when printing or faxing.
• Enhance your reports with electronic tools such as embedded links to references or other background information—even photos.
• Implement synoptic reports.
• If you use paper charts, consider how you present summary reports and how frequently they are replaced.
• Ask the report recipients for feedback about the information and its presentation. How could you improve the quality and usability of the reports?

Tell the Story
After you have implemented your reporting changes, toot your horn with the administration. Show them the before and after test result reporting formats. Share the metrics of the improvements, including the number of times the improvements will be encountered by clinicians, and the resulting positive impact on patient care.

Reference : College of Americal Pathologist website.(www.cap.org )

Immunopheotype of Gastrointestinal stromal tumours (GIST)

Histogenesis:
It has been suggested that GISTs originate from the interstitial cell of Cajal (ICC), or from a primitive stem cell that differentiates towards both the ICC and smooth muscle phenotye.

Sites:
GISTs occur at every level of the GI tract. Most tumours arise in the stomach (60%) and about
20–30% occur in the small intestine. Colorectal and oesophageal GISTs account for less than 10%. A small proportion of GISTs arise in extra-GI tract sites including the omentum, mesentery and retroperitoneum.

Morphologic patterns:
GISTs show a spectrum of histological features.Morphologically, the cells of GISTs are spindle, epithelioid, mixed pattern and occasionally pleomorphic.Spindle cell type is the predominant pattern, seen in 70% of GIST cases.

Immunophenotype
The overwhelming majority of GISTs express KIT protein (detected as CD117).The results of KIT immunostaining depend on several technical factors including fixation, tissue preparation, variations in antibody clones in terms of specificity and sensitivity, antibody dilutions and staining techniques. This may account, in part, for the reported immunophenotypic heterogeneity in GISTs. Recently, it has been emphasized that CD117should be performed without epitope retrieval.

Given the potential clinical importance of CD117 immunostaining, optimization of the staining techniques and reproducibility are critical. The pattern of staining is variable Diffuse strong cytoplasmic staining is the predominant pattern. Membranous staining and dot-like ‘golgi pattern’ staining can be identified. It has been suggested that different staining patterns correlate with different types of c-kit mutations. Stromal mast cells and ICC are useful internal positive controls to supplement the normal positive and negative controls.

Immunohistochemical detection of KIT does not necessarily imply c-kit activation. Indeed, CD117 is expressed by other tumour types such as melanoma and soft tissue sarcomas including dermatofibrosarcoma protuberans, synovial sarcoma and angiosarcomas. Therefore, CD117 immunoreactivity should be interpreted in the context of morphology and clinical setting.However, it is increasingly recognized that a high level of KIT expression is not characteristic for tumours with non-mutant KIT isoforms or tumours harbouring PDGFRA mutations.
CD34 is a transmembrane glycoprotein present on human haematopoietic progenitor cells and vascular endothelium. CD34 is detectable in approximately 70% of GISTs. The oesophageal and rectal GISTs have the highest frequency of CD34 positivity, whereas small intestinal tumours are the lowest percentage of CD34 positivity.

Actin expression is reported in approximately 30% of cases.Smooth muscle actin (SMA)expression is often reciprocal with CD34 expression: the SMA-positive tumours are often CD34 negative and vice versa. Some tumours may show a mosaic pattern with actin-positive and CD34-negative areas and vice versa.
Desmin-positive immunostaining is uncommon and, if present, is often limited to scattered tumour cells. Prominent staining is more common in epithelioid neoplasms. GISTs are generally negative for S100. Focal positive staining for cytokeratin markers can be seen especially in malignant epithelioid GISTs.

Proliferation markers (Ki-67, MIB-1 and proliferating cell nuclear antigen (PCNA)) may aid in tumour evaluation. It has been reported that tumours with more than 10% of nuclei that are positive for the KI-67 analogue are associated with metastases and poor survival rate.

In other studies, the MIB-1 index was not superior to mitotic count as a prognostic factor. Alterations of the tumour suppressor gene p16INK4A have been shown to be an independently poor prognostic factor.It has been previously regative p16 immunostaining is associated with malignant behaviour in GISTs.

GISTs with PDGFRA mutations are usually CD117 negative but may respond to STI-571; therefore, KIT detection may not be required for the treatment eligibility for Imatininb.



References:
1)Rubin BP, Fletcher JA, Fletcher CD. Molecular Insights into the histogenesis and pathogenesis of gastrointestinal stromal tumors. Int J Surg Pathol 2000;8:5–10.
2)Kindblom LG, Remotti HE, Aldenborg F, Meis-Kindblom JM.Gastrointestinal pacemaker cell tumor (GIPACT): gastrointestinal stromal tumors show phenotypic characteristics of the
interstitial cells of Cajal. Am J Pathol 1998;152:1259–69.
3) Miettinen M, Lasota J. Gastrointestinal stromal tumors—definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis.
Virchows Arch 2001;438:1–12.
4)M.Sabah et al.Gastrointestinal stromal tumours: An update.Current Diagnostic Pathology (2005) 11, 400–410

Significance of Atypical Small Acinar Proliferation (ASAP) in Prostate needle biopsy

Many time while reporting prostate needle biopsy, we come across features, which are suspicious for malignancy, but hinder a definitive diagnosis of carcinoma, because of concern about over diagnosis. These are the cases, which are labelled as ASAP, -atypical small acinar proliferation.

Diagnostic criteria for ASAP :
For pathologists, 3 questions need to be answered before the diagnosis of cancer in a small lesion:
• Would you be absolutely confident of this biopsy diagnosis if it were followed by a negative radical prostatectomy?
• Would another colleague pathologist agree with the diagnosis of cancer?
• Can you confidently support the diagnosis of adenocarcinoma based solely on this biopsy?

If the answer to any of these questions is “No,” then use of the more conservative diagnosis of ASAP is recommended.

Reasons for the Diagnosis of ASAP are :

• Small number of acini in the focus of concern.
• Small focus size, average 0.4 mm in diameter.
• Loss of focus of concern in deeper levels.
• Distortion of acini raising concern for atrophy.
• Lack of convincing features of cancer (insufficient nucleomegaly or nucleolomegaly).
• Foamy cytoplasm raising concern for foamy gland carcinoma.
• Conflicting immunohistochemical findings.

Significance of ASAP. -

Prostate cancer is found in up to 60% of repeat biopsies after the diagnosis of ASAP. Thus
ASAP in a biopsy is a significant predictor for concurrent or subsequent cancer. The high predictive value of atypical small acinar proliferation (ASAP) for subsequent adenocarcinoma indicates a need for repeat biopsy.

References:

1. Borboroglu PG, Sur RL, Roberts JL, et al. Repeat biopsy strategy in patients with atypical small acinar proliferation or high grade prostatic intraepithelial neoplasia on initial prostate needle biopsy. J Urol. 2001;166:866–870.
2. Cheville JC, Reznicek MJ, Bostwick DG. The focus of “atypical glands,suspicious for malignancy” in prostatic needle biopsy specimens: incidence,histologic features, and clinical follow-up of cases diagnosed in a community practice. Am J Clin Pathol. 1997;108:633– 640.
3. Iczkowski KA, Bassler TJ, Schwob VS, et al. Diagnosis of “suspicious for malignancy” in prostate biopsies: predictive value for cancer. Urology.1998;51:749 –757; discussion 757–748.

4. Isabelle Meiers, at el. Atypical Small Acinar Proliferation in the prostate :Pathology Case reviews • Volume 13, Number 4, July/August 2008;13: 129–134

Sentinel Lymph Node Biopsy in Melanoma (SLNB)

Clinical Significance of Sentinel Lymph node in melanoma. :

SLNB is very accurate in predicting the status of the remaining regional lymph nodes.
It is currently the most significant independent prognostic indicator for survival when compared with all other factors, including tumour thickness and the presence of ulceration.

According to some studies, the relapse rate for H&E detected SLN positive patients is higher (up to 67%), whereas the relapse rate for SLN negative patients is low (2–6%) during the same period.

Indications for SLNB procedure :

1. Primary Melanoma with thickness greater than 1.0 mm,
   or
2. Primary Melanoma less than 1mm with Clark's level four or five or presence of ulceration.

Pathology Protocol:

The current standard for the diagnosis of SLN metastasis is based on routine H&E histology and immunohistochemistry (IHC).
I follow the Cochran Method.It is as follows:
1. The lymph node is either bivalved or cut into 3 mm blocks, depending on the size of the node.
2. Sections 1, 3, and 5 are stained with haematoxylin and eosin (H&E),
3. Sections 2 and 4 are immunohistochemically stained for S-100 and HMB-45.

The sensitivity of detection is increased with IHC, multiple sectioning and reverse transcriptase polymerase chain reaction (RT-PCR) techniques. The role of such molecular genetic techniques in identifying melanoma proteins remains undefined, despite greater sensitivity.

Caution.:
‘‘Surgeons should be aware that the subcapsular region is crucial in sentinel lymph node (SLN) evaluation and the architecture of the SLN can be disrupted easily if the procedure is not carried out with care.’’

To reduce the false negative rate, surgeons should avoid crushing and excessive cautery usage to preserve the integrity of the SLN. It is also important not to cut into the SLN and complete excision of the whole SLN is crucial.

False positive results. :
False positives resulting from,

1. Benign naevic cells raise concern and necessitate further refinement. Naevic cells are usually present within the capsule (intracapsular) or within the trabeculae, and typically stain negatively, or only faintly positively, with HMB-45.


2. Reactive dendritic cells, nerve fragments, and benign naevic cells may each stain positively for S100. HMB-45 stain allowed us to differentiate benign naevic cells from their malignant counterparts.
   Examination at the subcapsular level, combined with the use of S100 staining, is the most practical and sensitive method to ensure the detection of micrometastatic nodal disease.
   

References:
· Gershenwald JE, Thompson W, Mansfield PF, et al. Multi-institutional melanoma lymphatic mapping experience: the prognostic value of sentinel node status in 612 stage I or II melanoma patients. J Clin Oncol 1999;3:976–83.
· Balch CM, Buzaid AC, Atkins MB, et al. Final version of the American joint committee on cancer staging system for cutaneous melanoma. J Clin Oncol2001;19:3635–48.
· White RR, Stanley WE, Johnson JL, et al. Long-term survival in 2,505 patientswith melanoma with regional lymph node metastasis. Ann Surg 2002;235:879–87.
· McCready DR, Ghazarian DM, Hershkop MS, et al. Sentinel lymph-nodebiopsy after previous wide local excision for melanoma. Can J Surg 2001;44:432–4.
· Cochran AJ, Huang RR, Guo J, et al. Current practice and future directions inpathology and laboratory evaluation of the sentinel node. Ann Surg Oncol 2001;8(9S):13–17.
· Jansen L, Nieweg OE, Peterse JL, et al. Reliability of sentinel lymph node biopsy for staging melanoma. Br J Surg 2000;87:484–9.
· C A Murray, W L Leong, D R McCready and D M Ghazarian Histopathological patterns of melanoma metastases in sentinel lymph nodes J. Clin. Pathol. 2004;57;64-67

Work up of Carcinoma of Unknown Primary (CUP)

It is often important to determine the site of origin of a metastatic carcinoma of unknown primary site, particularly because this may affect the choice of the treatment. Determination of the primary site may take several steps.
Clinical features, such as age, sex, and site of metastases may give a first indication.
A detailed pathologic examination of the most accessible biopsied tissue specimen is mandatory in CUP cases. Pathologic evaluation typically consists of hematoxylin-and-eosin stains and immunohistochemical tests. Electron microscopy is rarely used currently, although it may beselectively useful when making treatment decisions.
Role of Serum Tumor Markers and Cytogenetics
Most tumor markers, including CEA, CA-125, CA 19-9, and CA 15-3, when elevated, are nonspecific and not helpful in determining the primary tumor site.
Men who present with adenocarcinoma and osteoblastic metastasis should undergo a PSA test. Patients with an elevated PSA should be treated as having prostate cancer.
In patients with undifferentiated or poorly differentiated carcinoma (especially with a midline tumor), elevated Beta-human chorionic gonadotropin (B-hCG) and alpha fetoprotein(AFP) levels suggest the possibility of an extragonadal germ cell (testicular)tumor.
Cytogenetic studies had a larger role in the past, although interpretation of these older studies can be challenging. With the availability of immunohistochemical stains, cytogenetic cytogenetic analyses are indicated only occasionally.

Role of Immunohistochemistry
CK 7 and CK20 are two of the most commonly used CKs in surgical pathology.
A 5% cut-off percentage for positivity may eliminate more “false positive” results.

(1) CK7+/CK20+ in carcinomas of bile duct, lung-mucinous bronchioloalveolar, pancreas; urothelium; also primary mucinous tumors of ovary (74%), upper GI tract (78%), endocervix

(2) CK7+/CK20- in carcinomas of bile duct, breast, endocervical and endometrial adenocarcinoma, esophagus (distal,), lung (not mucinous, bronchioloalveolar), salivary gland, thyroid; also mesothelioma

(3) CK7-/CK20+ in carcinoma of colon (particularly early stage); CK20 is less sensitive for poorly differentiated colonic carcinoma; primary mucinous tumors of lower GI tract (79%,) and primary bladder adenocarcinomas (29%,)

(4) CK7-/CK20- in carcinomas of adrenal cortex and prostate

(5)CK7 and CK20 can be used to distinguish primary lung carcinoma (CK7+/CK20-) from metastatic colonic carcinoma to lung (CK7-/CK20+)

(6)CK7 cab be used to distinguish chromophobe carcinoma (diffuse CK7+ staining) and oncocytoma (usually CK7-)

(7)CK 20 can be used to distinguish Merkel cell carcinoma (CK20+, dot like, TTF1 -) and metastatic small cell carcinoma of lung (CK20-, TTF1+)

Additional immunostains for further work up.
BRST-1,ER,PR,Gross cystic disease fibrous protein-15--> Breast cancer
Thyroid transcription factor 1---> Lung and thyroid cancer
Thyroglobulin ---> Thyroid cancer
Chromogranin, synaptophysin, NSE,CD56---> Neuroendocrine cancer
CDX-2 ---> Gastrointestinal cancer
Calretinin, mesothelin---> Mesothelioma
Leukocyte common antigen---> Lymphoma
S-100, HMB-45---> Melanoma
URO-III, thrombomodulin ---> Bladder cancer
AlphaFetoprotein ---> Hepatocellular cancer, germcell cancer
Beta-Human chronic gonadotropin --->Germ cell cancer
Prostate specific antigen ---> Prostate cancer
Please review following powerpoint presentation for work up of CUP.

Use of algorithm in IHC

Molecular Cancer Pathology Update

Genetic variant may eventually enable clinicians to differentiate between aggressive, indolent prostate tumors.
Medscape reported, "One of the biggest issues in prostate cancer is differentiating between men who have aggressive tumors that could be fatal and men who have indolent tumors that might never become clinically significant."

But, findings from a University of California-San Francisco study may ease some of that difficulty. The team identified a genetic variant, which "is located on the KIAA1217 gene," saying that "it shows a person's predisposition to aggressive prostate cancer." The hope is that it will, will enable clinicians to identify with more certainty men who are likely to have aggressive disease," which "could result in less overtreatment."

Updates on Molecular Cancer Pathology

1) Molecular profiling may help determine patient's response to cancer therapies, research suggests.
A pilot study of molecular profiling of tumors, helped to identify therapies that ultimately had an impact on the disease.The University of Texas MD Anderson Cancer Center and the Memorial Sloan-Kettering Cancer Center are "striving to profile individual tumors so that therapy can be personalized, which means that it has a better chance of working because it targets specific mutations found in that tumor. This also prevents patients from being exposed to drugs that have a limited chance of success, eliminating toxicity and improving quality of life.

2 )Scientists developing new techniques for detecting CTCs in cancer patients' blood-Medscape report
Measuring "circulating tumor cells (CTCs) in the blood of cancer patients" gives "an indication of whether or not the patient is responding" to treatment. Presently, "there is only one commercially available product to measure CTCs -- CellSearch (Veridex LLC)." Now, one device in development "promises to be cheaper and faster," say University of California-Los Angeles researchers. The "new technique is based on a microfilter device."

3) Bladder cancer cells may have two distinct genetic patterns, research suggests.
Bladder cancer cells have two distinct genetic patterns, depending on whether they are invasive or not," say University of Southern California-Los Angeles scientists. The "discovery opens the possibility of monitoring the disease by a simple urine test," which would enable clinicians to sidestep "invasive procedures."

4) Immune cells could be reprogrammed to attack prostate cancer, scientists say.
Reprogrammed immune cells could become targeted 'killing machines' against prostate cancer." In fact, "these reprogrammed T cells sharply reduced the levels of prostate specific antigen (PSA) in two patients with metastatic prostate cancer," scientists at the Roger Williams Medical Center said. But first, the team had to "isolate a patient's T cells from a blood sample and use genetic engineering techniques to make them sensitive to a molecule that only occurs in prostate cancer -- prostate specific membrane antigen, or PSMA."

5) Researchers say presence of certain variants in MC1R gene may increase melanoma risk.
Researchers from the University of Pennsylvania "analyzed 779 patients with melanoma and compared them to 325 healthy people." The investigators found that the "presence of certain variants in the MC1R gene was linked with at least a twofold increased risk of melanoma, and was largely confined to those people who would not normally be considered at increased risk."

False positive diagnosis in breast FNAC.

Some common lesion leading to false positive diagnosis in FNA of breast are listed with Keys to differentiate them.
Artifactual Atypia
Most common of these is disruption of cell aggregates by too vigorous smearing, which can mimic the loss of cohesion characteristic of malignant epithelial cells .
Excessive smearing pressure can also cause smudging of nuclei, giving a false impression of nuclear enlargement and pleomorphism.
Dying artifacts in alcohol-fixed Pap smears have a similar effect.

Hormonal Stimulation and Physiologic :Hyperplasia in Pregnancy and Lactation
Physiologic hyperplasia of acinar epithelial cells in late pregnancy and lactation can look worrying in FNA smears.
Key: The recognition of milky secretion is the main clue to a correct diagnosis to be correlated with clinical information.

Reactive Atypia
This is seen in mastitis fat necrosis, postoperative repair, and post radiation.
Key: Correct clinical information is important. A history of previous tissue injury and the presence of acute inflammatory cells (not just lymphocytes) rarely seen in breast cancer call for caution and careful evaluation of the nuclear structure of atypical cells.

Fibroadenoma
Epithelial atypia, most likely hormone related, can be prominent in smears of fibroadenoma. This is the most frequent cause of false positive diagnosis in breast FNA.
Key: In most cases, the atypical cells constitute only a minor part of the cell population. The presence of benign components is a safeguard against an erroneous malignant diagnosis.

Papillary Lesions
The combination of high cellularity, loss of cell cohesion, and variable nuclear atypia sometimes seen in smears from benign papillary lesions may raise a suspicion of malignancy. A false positive diagnosis is possible, particularly if a papillary microarchitecture is notidentified.
Key: In general, the presence of background apocrine cells, foam cells, and single bipolar nuclei suggest a benign papilloma.
REFERENCES
1. Franze´n S, Zajicek J. Aspiration biopsy in diagnosis of palpable lesions of the breast. Acta Radiol. 1968;7:241–262.
2. Zajdela A, Ghossein NA, Pilleron JP, et al. The value of aspiration cytology in the diagnosis of breast cancer: experience at the Foundation Curie. Cancer. 1975;35:499–506.
3. Greenberg M. Diagnostic pitfalls in the cytological interpretation of breast cancer. Pathology. 1996;28:113–121.

Reporting parameters for positive prostate needle biopsy

According to college of American pathologists (CAP)the mandatory items for reporting positive prostate biopsies are:

• Histologic type - typically adenocarcinoma (conventional/acinar, not otherwise specified)
• Histologic grade –primary (predominant) Gleason pattern + secondary (worst remaining) Gleason pattern
• Total Gleason score
• Tumour Quantitation - 3 possible methods for tumor qyuantification;
  1) % of prostatic tissue involved by tumour
  2 ) total linear mm of carcinoma
• 3) number of positive cores/total number of cores
  
• Periprostatic fat and seminal vesicle invasion should always be looked for and reported if identified, given their importance in developing an optimal treatment plan.

Optional parameters

• Reporting the presence or absence of perineural invasion and lymphatic/small vessel invasion is completely optional.


• Perineural invasion is of debatable prognostic significance and we likely continue to reported simply because we have always done so.


• Reporting the presence of high grade PIN in biopsies with adenocarcinoma is also completely optional.


• Interestingly, inflammation is listed as an optional item. It has been my experience that many clinicians will be interested in knowing about coexisting inflammation in positive biopsies (especially if it is appreciable in amount) as it may be of use in interpreting serum PSA at the time of the positive biopsy.
  

Importance of Immunohistochemistry in the Evaluation of follicular lymphoid lesion

Before discussing the utility of particular immunostains, it is important to review and understand some basics about the normal lymphoid follicle, in order to interpret the immunostains appropriately.
The difference between a primary follicle and a secondary follicle:
A primary or "resting" follicle: - a collection of B-cells in the cortex of the lymph node that has not been antigenically stimulated, and because of this, it does not have a germinal center.
A secondary follicle:- Once a primary follicle has been antigenically simulated, it acquires a germinal center, and at this point is referred to as secondary follicle.
Differential diagnosis of lymphoid lesion with follicular structures or nodules, :-
1) Resting (primary) follicles,
2) Secondary follicles (as a reflection of reactive follicular hyperplasia),
3) Follicular lymphoma,
4) Mantle cell lymphoma with a nodular growth pattern.
5) B cell SLL/CLL with prominent pseudofollicular proliferation centers.

Many times the distinction of non-neoplastic lymphoid follicles vs. neoplastic lymphoid follicles can be readily made on standard H&E morphology alone.
As we all know however, we see cases where this distinction is challenging, and in other situations we are faced with minuscule or suboptimal material.By understanding the expected phenotype of the lymphoid cells within each of the various types of lymphoid follicles, one can frequently render a confident diagnosis, even in the face of suboptimal material or a minimal biopsy sample.

The lymphocytes in primary (resting) follicle express B cell markers (such as CD20, CD79a, or Pax-5) and BCL2.CD23 may be positive or negative, but they lack BCL6,CD10, CD5, and cyclin D1, and they have a low Ki-67 proliferative fraction.
In contrast, in the germinal center of a secondary follicle, the lymphoid cells lack BCL2, CD5,CD23, and cyclin D1, express both BCL6 and CD10, and have a very high proliferative fraction, approaching 100%.
In follicular lymphoma, the neoplastic cells express B-cell markers, BCL2 and BCL6, and lack CD5, CD23 and cyclin D1, with a variable Ki-67 proliferative fraction. Most but not all follicular lymphomas express CD10, and some grade 3 follicular lymphoma lack BCL2.
In mantle cell lymphoma, the lymphocytes express B-cell markers, BCL2, CD5, and cyclin D1, typically lack BCL6 and CD23.
And finally, in B-cell small lymphocytic lymphoma/CLL, the neoplastic cells express B-cell markers,CD5, CD23, and BCL2, but lack BCL6, cyclin D1, and CD10.

Caveats for immuno interpretation:
Since some of these follicular or nodular structures to some extent consist of mixed B and T-cell populations, there are often minor populations of cells staining for the markers above that are listed as lacking, and for that reason in some cases it is easiest to interpret the immunostain results on low-power.
For example, in the case of primary (resting) follicles, there are often a small number of background cells that may express BCL6, CD10, and CD5. It is always a good idea to compare the extent of reactivity of the markers discussed with the extent of reactivity of the associated B cell markers. Finally, it must be kept in mind that CD23 stains a subset of the follicular dendritic cells (FDC) that may be present in these conditions, so care must be taken to not misinterpret CD23 reactivity of FDC as reactivity of the lymphocytes. Finally, it is worthwhile to note that some follicular lymphomas contain impressive numbers of non-neoplastic T-cells. Another point that must be made is this: "tumors do not read textbooks". As such, not all lymphoid proliferations will neatly fit into the expected patterns of reactivity discussed
above. For example, we have seen clear-cut cases of both follicular lymphoma and mantle cell lymphoma that have expressed strong CD23, a few mantle cell lymphomas that have expressed BCL6, and we have even seen a rare case of follicular lymphoma that expressed CD5.

Click on the images to enlarge them.

References:
1) CD10 and BCL-6 expression in paraffin sections of normal lymphoid tissue and B-cell lymphomas.Dogan A, Bagdi E, Munson P. Am J Surg Pathol. 2000 Jun;24(6):846-52.
2) Abnormal expression of bcl-10 protein in extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue lymphoma typeLi BZ, Zhou XY, Ye HT, Yang WT, Fan YZ, Lu HF, Shi DR. Zhonghua Bing Li Xue Za Zhi. 2007 Dec;36(12):819-24. Chinese.
3) Propath focus –Immunohistochemistry in the Evaluation of Follicular or Nodular Lymphoid Lesions, R. T. Miller, M.D

Sentinel Lymph Node Mapping-Pathology Protocol in Breast Cancer.

Sentinel Lymph Node Mapping-Pathology Protocol.

Sentinel lymph node mapping is now performed on selected patients who opt for conservative surgery to treat their breast cancer.
The procedure involves the surgical identification of those axillary lymph nodes that theoretically would be the first ‘‘sentinel’’ nodes to receive the lymphatic drainage from the breast harboring the invasive cancer. If these nodes are pathologically negative, the patient is spared the morbidity associated with a standard axillary node dissection.

Surgical identification is based on the peritumoral injection of radioactive solutions and/or colored dyes. The surgeon then massages the breast to facilitate permeation of the solution into the lymphatic system. Several hours after the injection, the patient is taken to the operating room, where the surgeon uses a radioactive counter to locate the ‘‘hot’’ lymph node. If a colored dye has been used, visual inspection of the axilla usually identifies the sentinel lymph node. Usually, the pathologist receives 1 to 3 lymph nodes for evaluation.

Some centers use cytologic imprints, either with or without frozen section evaluation,at the time of surgery to determine whether the sentinel node is involved by metastatic tumor. If the imprintsare positive, then the surgeon proceeds to an axillary node dissection. Other hospitals submit their sentinel lymph node biopsies for routine processing without intraoperative consultation.
Once the specimen is received in the pathology laboratory, the pathologist must carefully dissect out all the nodes and record the number and sizes. If it is technically feasible, each node should be serially sectioned at 2- to 3-mm intervals, parallel to the long axis, and entirely submitted for evaluation. One hematoxylineosin–stained section should be cut from each block for light microscopy. Additional unstained levels may also be requested at the time of sectioning, in the event that immunohistochemical analysis of the node will be required to confirm the diagnosis of metastatic disease. Although some studies advocate using immunohistochemistry on all histologically negative lymph nodes, the current College of American Pathologists guidelines state that this procedure is not the standard of care for pathologic evaluation of sentinel lymph nodes in patients with invasive breast cancer.

Metastasis and prognosisMacrometastases (>2 mm) have a clear influence on prognosis
Micrometastases (>0.2 mm, < or =" 2">
References:
Cserni G. Evaluation of sentinel lymph nodes in breast cancer. Histopathology 2005;46:697–702.
Weaver DL. Pathological evaluation of sentinel lymph nodes in breast cancer: a practical academic perspective from America. Histopathology 2005;46:702–6.
Bobrow L, Pinder S. Histopathology and the SLN. In: Sentinel lymph node biopsy handbook—NEW START. London: RoyalCollege of Surgeons of England; 2004. p. 88–94.

Errors in Surgical Pathology

Errors in Anatomic Pathology
Extracts of the interview with Dr. Stephen Raab, Professor of Pathology, Vice-Chair for Quality and Director of Anatomic Pathology at the University of Colorado, Denver.
Q: How many errors have been reported to date ?

Dr. Raab: There are now more than 25,000 errors in the database.

Q: What are some area for quality improvement in anatomic pathology?
Dr. Raab: Quality improvement is more effective if there are simultaneous efforts to improve quality in specimen collection, laboratory processing, and pathologist interpretation, rather than just focusing on error in pathology interpretation.

Q: Error detection is critical to quality improvement. How are errors usually detected in anatomic pathology?
Dr. Raab: The two most common methods of error detection are cytologic-histologic correlation and secondary review of previously reported cases.

Q: What kind of errors do these methods detect?
Dr. Raab: They detect many different errors including mislabeled specimens, suboptimal specimens -for example a cytology or histology specimen that fails to sample the cancerous area of a mass-, and errors in interpretation by a pathologist.

Q: What is your general approach to interventions to decrease errors in anatomic pathology?
Dr. Raab: Enhanced communication. Disconnection between pathologists and direct care providers is a significant latent source of errors in pathology. When pathologists communicate more frequently with care providers, the quality of the pathologist's work improves because both the clinician and pathologist are better informed about the patients.
some examples of enhanced communication between pathologists and care providers are as follows:
1) Pathologists calling their diagnosis directly to the physician caring for the patient,
2) Increasing the number of conferences at the multiple-headed scope with both pathologists and care providers present,
3) Having the pathologist physically present when a different physician collects a fine needle aspirate.
4) The specimen collector, who is often a direct care provider or radiologist, receives immediate feedback from the pathologist regarding the adequacy of the specimen.
Using a checklist in the gynecologist office to maximize the likelihood of an adequate specimen.

Q: Besides increased communication, what other interventions do you favor regarding decreasing errors in pathologist interpretation?
Dr Raab: The key to decreasing errors in pathologist interpretation of an adequate specimen is standardization. Standardization is basically an agreement that work is going to be done a certain way. It requires that standards be developed at a national or international level, than adhered to by each pathology practice. To achieve standardization, the pathologists in the practice must work together as a group and apply methods such as:
1) Reviewing a sampling of each other's cases
2) Meeting frequently around the multiple-headed scope to decide cases by a consensus-building process.
Practices dominated by individualists or egotists tend to resist change and have trouble standardizing. Unfortunately, many practicing pathologists strongly resist standardization.

Q: What is the "Big Dog" effect ?
Dr. Raab: At many institutions, there is a dominant senior pathologist, the Big Dog, who becomes the gold standard of anatomic pathology. The other pathologists follow the diagnostic beliefs of the Big Dog, and defer to the Big Dog on difficult cases and in the analysis of the cause of an error.

Q: What are the problems caused by Big Dogs?
Dr. Raab: There is a poor agreement between Big Dogs from different institutions in their interpretation of a particular case. This makes it hard to achieve standardization regarding a diagnosis. In addition, Big Dogs agree poorly regarding their assessment of the causes of an error. This hinders quality improvement, since judgments regarding root causes of an error provide a guide for the choice of interventions.

References:
1. Raab SS et al. Patient safety in anatomic pathology: measuring discrepancy frequencies and causes. Arch Pathol Lab Med. 2005;129:459-466.
2. Raab SS et al. Errors in thyroid gland fine-needle aspiration. Am J Clin Pathol. 2006;125:873-882.

Importance of Tissue fixation in Cancer management

“Do you want a quick result, or the right result?”

There is always a pressure on the laboratory (and the pathologist) to turn specimens around quickly, so that decisions can be relayed to anxious and expectant patients.

Proper specimen handling and preparationhas been under-appreciated by clinicians and pathologists alike.How preanalytical variables such as tissue handing and tissue fixation have the potential to significantly and adversely affect the accurate assessment of therapeutic targets such as ER/Her2neu in tumor specimens.,must be understood properly.

Following are the Consensus Recommendations on Estrogen Receptor Testing in Breast Cancer By Immunohistochemistry by Members of the Standardization Ad-Hoc Consensus Committee.

1. As soon as they are available from the operating room, breast specimens with a known cancer, or a suspicion of cancer, should be oriented, inked, carefully sectioned at 0.5 to 1 cm intervals and placed in the appropriate volume of fixative with gauze pads or paper towels in between slices to assist with the penetration of fixative into all areas of the tissue.


2. In addition,if gross tumor is easily identifiable, the pathologist (or pathology assistant) should remove a 2-mm thick sample of tumor, together with a 2-mm thick sample of benign tissue and place both into the same cassette at the time of the initial evaluation, thus ensuring that normal breast elements are available as appropriate internal tissue controls for subsequent breast marker testing.


3. Breast core biopsies should be fixed and processed in an identical manner to excision specimens.


4. Only 10% aqueous phosphate-buffered 4% formaldehyde pH 7.0-7.4 (10% phosphate-buffered formalin) should be used as the fixative for breast tissue samples.


5. Minimum fixation times of at least 8 hours optimally 24 to 48 hours, not to extend to more than 72 hours are recommended for all laboratories accepting breast tissue samples.

There is a misconception that smaller biopsy samples will fix more quickly than larger resection specimens and therefore require less time in formalin. It is true that formalin will penetrate smaller samples more quickly than larger samples, but actual fixation is a chemical reaction that takes time.Penetration time of formalin is of little importance than the chemical reaction time .For example, a single layer of cells is penetrated by formalin extremely rapidly, however the chemical reaction requires 24 hours to complete. A 4-mm thick slice of tissue is fully penetrated within an hour and requires 25 hours for the chemical reaction to complete.

Having a record of the fixation time for each breast tissue sample is expected to prove valuable for interpreting and troubleshooting aberrant and/or unexpected ER results.One such example would be when an ER IHC assay is found to be negative in a well-differentiated cancer such as a tubular carcinoma or a classic lobular carcinoma. This result would be unexpected, and having access to the details on tissue fixation, such as a long delay before the initiation of fixation or short fixation time in formalin would be valuable in interpreting the validity of the unexpected results for such a patient.

Reference:

Consensus Recommendations on Estrogen Receptor Testing in Breast Cancer By Immunohistochemistry;Hadi Yaziji et al.Apllied immunohistochem Mol.Vol16,Dec.2008

Measuring size of DCIS

Measuring Size (Extent) of DCIS

Although not required for pT classification or stage assignment, the size (extent) of DCIS is an important factor in patient management. Although a precise measurement is often not possible, an estimate of the extent of DCIS is clinically important.

Size /Extent of Ductal Carcinoma In Situ (DCIS) and Clinical Significance
DCIS Size/ Extent
Up to 2 cm:Breast conservation with wide negative margins can be achieved in most women.
>2-4 cmWide negative margins may be difficult to achieve in some women with breast-conserving surgery.

>4 cm
Breast conservation with wide negative margins may be impossible to achieve in some women.
There is a possibility of undetected areas of invasion if the area involved by DCIS is not completely examined. Lymph node sampling may be recommended.

Methods to measure DCIS:
DCIS in One Block:
The area involved by DCIS can be measured from a single slide, if DCIS is present in only one block. If separate foci are present on the same slide, the largest distance between foci should be reported. This method will underestimate the extent of DCIS when multiple blocks are involved, and should not be used in such cases.
DCIS in multiple blocks in case of Serial Sequential Sampling:

The entire specimen is blocked out in such a way that the location of each block can be determined. The extent of the DCIS can be calculated by using a diagram of the specimen, the thickness of the slices, and the location of the involved blocks. This method is recommended for all excisions likely to harbor DCIS or with previously diagnosed DCIS (eg, by diagnosis on a prior core needle biopsy).

DCIS in case of Nonsequential Sampling:

Multiplying the number of blocks involved by DCIS by the approximate width of a tissue section gives an estimate of the extent. ( multiplying by 0.4 cm is recommended,which is size of tissue thickness)

Specimen sampling to measure size of DCIS:

For specimens with a known diagnosis of DCIS (eg, by prior core needle biopsy) it is highly recommended that the entire specimen is examined using serial sequential sampling to exclude the possibility of invasion, to completely evaluate the margins, and to aid in determining extent.If an entire excisional specimen or grossly evident lesion is not examined microscopically, it is helpful to note the approximate percentage of the specimen or lesion that has been examined.

References:

1. Silverstein MJ, Poller D, Craig P, et al. A prognostic index for ductal carcinoma in situ of the breast. Cancer. 1996;77:2267-2274.
2. Grin A, Horne G, Ennis M, O’Malley FP. Measuring extent of DCIS in breast excision specimens: a comparison of four methods. Arch Pathol Lab Med. 2009;133:31-37.
3. Dadmanesh F, Fan X, Dastane A, Amin MB, Bose S. Comparative analysis of size estimation by mapping and counting number of blocks with DCIS in breast excision specimens. Arch Pathol Lab Med. 2009;133:26-30.

4. ww.cap.org

HER2/neu Marker in Breast Cancer

Quality Management Requirements for HER2/neu Marker in Breast Cancer
Recommendations of the HER2/neu Advisory Committee,Ontario,Canada

The testing laboratory must have an established immunohistochemistry program with sufficient volume to maintain technical/professional knowledge and skill. (The UK guidelines recommend performance of 250 IHC and, if applicable, 100 FISH tests per year1). For Ontario, we recommend a minimum of 20 HER2/neu IHC tests per month or 240 HER2/neu tests per year.

The laboratory must have a quality assurance improvement program that provides for the required quality control and uses quality indicators to determine whether performance is meeting the quality standard.

At least one pathologist from each centre, involved in the reading and interpretation of
immunohistochemical preparations in situ hybridization for HER2/neu, must complete appropriate training.

Quality Assurance Requirements - To be read in conjunction with the Testing Algorithm Schematic
It is recommended that tissue be fixed with 10% phosphate buffered formalin (4% formaldehyde),pH 7.0. The optimal fixation time is 8 to 48 hours.
Antibodies currently used in Ontario include monoclonal antibody CBll (Novocastra), monoclonal antibody TAB250 (Zymed), polyclonal antibody A0485 (DAKO) and the HercepTest Kit (DAKO). Assays using these antibodies have been optimized and instructions must be followed precisely. Other appropriately validated antibodies may be used.

If immunohistochemical detection of HER2/neu is carried out using more than one antibody then the antibodies should be directed at different epitopes.

If the findings with the second IHC antibody remain equivocal/indeterminate, in-situ hybridization (FISH or chromogenic in-situ hybridization [CISH]) testing is required.

Controls using tissue and, if possible, cell lines demonstrating high, intermediate and low level HER2/neu amplification, should be run in parallel with patient testing. Patient tests must be repeated when the controls are non-conforming. The report should include an estimate of the % positive cells as well as intensity of staining. If the HercepTest kit is used, the recommended scoring system of 0-3+ should be reported as well as the percentage of positive cells.

The target turnaround time from receipt of the tissue block in the laboratory to report should be within one week and not longer than two weeks. The laboratory must confirm indeterminate IHC results using either FISH / CISH or arrange to have such confirmation carried out by a named referral laboratory that has agreed to provide this service.

Approximately 15 to 30% cases may require FISH. The laboratory must document and maintain a record of the number of patient samples processed and the number of positives, negatives and indeterminates. The percent positives should be calculated on a regular basis as one of the quality indicators.

REFERENCES
1. Ellis 10, Bartlett J, Dowsett M et al. Updated recommendations for HER2/neu testing in the UK. J Clin Pathol, 2004;57:233-237.
2. W. HannaF,P O'Malley. Updated recommendations from the HER2/neu consensus
meeting-Toronto, Ontario, September 2001. Current Oncology. 2002; 9 (Suppl. 1): S18-
S19.

Quirke's Method For Dissecting Colorectal Adenocarcinoma

Quirke's Method For Dissecting Colorectal Adenocarcinoma.
This is Philip Quirke's method for assessing colorectal adenocarcinoma as demonstrated for the MRC-CR07 trial participants. The first step is to assess the colon for completeness of mesorectal excision. A grade of 1, 2 or 3 (3 is best) is given.
Gross pathologic assessment of completeness of mesorectal excision (i.e. complete excision of the rectal mesentery or mesorectal fat pad) be reported on all rectal cancers. The purpose of this is to identify those patients who are more likely to recur postop., giving prognostic information and thus affecting followup . There is no doubt that complete mesorectal excision will reduce local recurrence rates (from 30-40% without TME, down to 3.7% with TME (as reported by Heald).

Quirke's graded assessment of completeness of mesorectal excision (MRC trial)
3-Good: Intact mesorectum with only minor irregularities of a smooth mesorectal surface. No defect is deeper then 5 mm. No coning on the specimen. Smooth CRM on slicing.

2-Moderate: moderate bulk to the mesorectum but irregularity of the mesorectal suface. Moderate coning of the specimen towards the distal margin. At no site is the m.propria visible with the exception of the insertion of levator muscles. Moderate irregularity of CRM.

1-Poor: Little bulk to mesorectum with defects down onto m.propria and/or very irregular cirumferential resection margin.

Notes
- Coning refers to the tendency for the surgeon to cut towards the colon and breachthe mesorectal envelope as he goes distal rather than staying outside the mesorectal plane. This gives a tapered conical appearance rather than a bulky distal mesorectal fat pad. This can also lend a ragged appearance to the specimen since the surgeon may realize his mistake and go outside the mesorectum to find the correct plane once again, leaving gashes in what should be a smooth mesorectal surface.
- Is it possible for the entire mesorectum to be removed even though it has a ragged appearance? Yes, but it doesn't matter. Once the mesorectum has been violated the risk for spillage of tumour from lymphatics exists. A ragged specimen without a smooth surface must therefore be a grade 2.

Guidelines for Colo rectal resection: Margins and lymph nodes

Optimization of Pathological Quality Performance in Radical Surgery for Colon and Rectal Cancer: Margins and Lymph Nodes Guideline Recommendations : Cancer Care Ontario,Canada


Question:
What is the recommended approach to processing and reporting the resected specimen, including specimen marking in the operating room, as well as processing and reporting requirements in the pathology laboratory?
Answer:Proximal and Distal Margins
The surgeon should communicate with the pathologist regarding the orientation of the specimen.
Proximal and distal margins should be sampled for histological examination.
The distance of the tumour to the proximal and distal margins should be reported in the fresh state, if possible. Measurement in the fixed state must take into account the fact that shrinkage will have occurred; pinning the fresh specimen to a board, under tension, will produce less shrinkage. If the tumour is close to a margin, the distance between the tumour and the margin of concern should be reported as measured microscopically on the glass slide.
Radial Margins
The surgeon must clearly indicate to the pathologist areas with close contact to other organs or the abdominal wall. The pathologist should be aware of the retroperitoneal margin that exists in certain locations (e.g., proximal ascending colon and descending colon).
The radial margins of the resected specimen should be inked and sectioned.
The radial margin distance must be reported. The radial margin should be reported as positive if tumour is located 1 mm or less from the inked nonperitonealized surface of the specimen.


Margins of Resection: Rectum
Technical Recommendations

Technical recommendations are based on the Expert Panel consensus informed by the technical issues highlighted in four key papers in the field (2-5), as well as pathology studies identified in the recent literature search.


Proximal and Distal Margins
Proximal and distal margins should be sampled for histological examination.
Pathologists should pay close attention to mesorectal soft tissue, in addition to the mucosa, when assessing the distal margin.
Circumferential Radial Margins
All rectal cancer specimens should be assessed grossly by the pathologist using the method developed by Quirke .
The mesorectal tissue that constitutes the CRM, including all non-peritonealized bare areas anteriorly and posteriorly, should be inked. The specimen should be
fixed with the tumour segment unopened 5 cm above and below the proximal and distal edges of the tumour, respectively, and a gauze wick placed into the unopened segment to facilitate fixation. Following at least 48 hours of fixation, the segment with the tumour should be sliced into transverse sections. The relationship of the tumour to the CRM must be carefully assessed.
The CRM distance must be reported. The CRM is positive if the tumour is located 1 mm or less from the margin; this includes tumour cells within a lymph node, vein, or nerve, as well as direct tumour extension.
Note that tumours of the upper rectum have a peritonealized anterior surface and a non-peritonealized posterior radial margin similar to the ascending and descending colon.


Serosal Penetration
Involvement of the serosa by tumour (pT4b) is not equivalent to involvement of the radial margin by tumour (although there are circumstances in which an advanced tumour has penetrated the serosa and is adherent to adjacent soft tissue).
Documentation of serosal involvement by tumour requires careful gross and microscopic examination and may require extensive sampling and/or serial sectioning of sampled tissue blocks.Serosal penetration is defined as occurring when any of the following criteria are met:
Free tumour cells are present on the serosal surface with underlying ulceration.
Tumour is present at the serosal surface with an associated inflammatory reaction, mesothelial hyperplasia, and/or erosion or ulceration.
The tumour is close to, but not at the serosal surface but there is an associated mesothelial inflammatory and/or hyperplastic reaction.


Serosal penetration is an independent prognostic variable and has a strong negative impact on prognosis. The frequency of distant metastasis is greater in cases with perforation of the visceral peritoneum compared to cases with direct invasion of adjacent organs or structures without perforation of the visceral peritoneum, and the median survival time following surgical resection for cure is shorter for patients with pT4b tumours compared to those with pT4a tumours (with or without distant metastasis).


Lymph Node Assessment

Technique of Lymph Node ExaminationTechnical recommendations are based on Expert Panel consensus informed by four key papers in the field (2-5) and pathology studies identified in the recent literature search.
Pericolic fat should be carefully examined using inspection and palpation. For colonic tumours, examination should occur after pericolic fat has been stripped off the colon and after any appropriate sections have been taken to evaluate the radial margin.
In the case of rectal tumours, the cross-sectioned slices are examined for lymph nodes, taking care not to double count lymph nodes that might be present in more than one cross-sectional slice.
All lymph nodes present must be examined histologically. Nodal examination must not stop once 12 nodes have been identified. It is particularly important to find small lymph nodes close to the underlying bowel wall. If less than 12 lymph nodes are
found, consideration should be given to placing the fat into a lymph node highlighting solution.
All grossly negative or equivocal lymph nodes must be submitted in their entirety. However, if a node is grossly positive, partial submission is acceptable.
Number of Lymph Nodes Assessed
Technical Recommendations
Technical recommendations are based on Expert Panel consensus informed by four key papers in the field (2-5) and pathology studies identified in the recent literature search.
The pathology report should indicate the number of positive lymph nodes as well as the total number of nodes assessed.
The number of lymph nodes involved by micrometastases (tumour deposits >0.2 mm but <2.0>

RELATED GUIDELINES
Practice Guideline Report #2-20-2: Laparoscopic Surgery for Cancer of the Colon, September 2005
Practice Guideline Report #2-9: Follow-up of Patients with Curatively Resected Colorectal Cancer, January 2004
Diagnostic Imaging Recommendations Report: Cross-sectional Imaging in Colorectal Cancer, April 2006
Multidisciplinary Care Conference Standards, June 2006
Evidence-Based Series: #2-29: Adjuvant Systemic Chemotherapy for Stage II and III Colon Cancer Following Complete Resection, April 2008
Evidence-Based Series #2-4: Preoperative or Postoperative Therapy for the Management of
Patients with Stage II or III Rectal Cancer [In progress]

Papillary Thyroid Ca Criteria in Cytology

Papillary Thyroid Ca Criteria in Cytology (Kini)

5 criteria "Definite"; 4 criteria "Suspicious"; 3 criteria "Follicular Lesion"

Adequate Specimen: 6 clusters of 10-15 cells

1 Syncytial tissue fragments
2 Enlarge nuclei with fine dusty chromatin
3 Multiple micro and or macro nucleoli
4 Intranuclear inclusions
5 Nuclear grooves

Papillary Thyroid Ca Diagnostic Criteria in Histology

4 Major or (3 Major + 4 Minor required)

Major Criteria
1 Nuclei oval (not rounded)
2 Nuclei crowded, manifesting as lack of polarization in cells lining a follicle and overlapping nuclei
3 Pale chromatin esp. at the edge of the tissue where well-fixed
4 Psammoma bodies

Minor Criteria
1 Abortive papillae
2 Elongated or irregular follicles
3 Dark staining colloid
4 Rarely nuclear pseudo inclusion
5 Multinucleated histiiocytes in lumens of follicles
6 Grooves


Ref:
1 Chan JKC Strict criteria should be applied in the diagnosis of encapsulated follicular variant of papillay thyroid ca. AJCP 2002;117:16-18
2 Balock ZW, LiVolsi VA Follicular-patterned lesions of the thyroid. AJCP{ 2002;117:143-150

Guidelines for Radical Prostatectomy Specimen Handling

Guideline for Optimization of Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management:CANCER CARE ONTARIO,CANADA GUIDE LINES.

Pathological Questions

1. What are the recommended procedures for handling the RP specimen in the operating
room and for handling and processing the RP specimen (with or without lymph nodes)
in the pathology lab?
2. What diagnostic and prognostic elements should be included in the pathology report,what format should be used, and what reporting elements should be included?

Answers:

(1)Handling of the Radical Prostatectomy Specimen in the Operating Room

• Frozen section analysis of the radical prostatectomy specimen (RPS) for margin status is not recommended.
• For routine handling, the RPS should be fixed in 10% neutral buffered formalin or other appropriate fixative. The specimen should be put in an appropriately sized container with a minimum formalin/tissue ratio of 10:1 (i.e., 500 cc formalin for a 50 cc prostate).

Pathology Requisition Information
• The surgical specimen should be accompanied by an appropriate pathology requisition
that includes demographic and other identifying information, relevant clinical data (e.g.,serum PSA, DRE findings [T1c versus T2], Gleason score on biopsy), and the history of neoadjuvant therapy (e.g., hormones )

Pathology Report
• The surgical pathology report should include the relevant diagnostic and prognostic information as outlined in the CAP Cancer Protocol for Carcinomas of the Prostate Gland
(2) CCO has recommended as a minimum standard that all mandatory elements on the CAP checklist (Section 2: Appendix 2) be included in the RPS pathology report.
• It is recommended that the diagnostic and prognostic factors be presented as a synopsis as opposed to a narrative or paragraph form. Data from CCO indicates that synopses are more likely to be complete.

Technical Considerations for Handling and Processing the Radical Prostatectomy Specimen in the Pathology Laboratory
• In the Pathology Laboratory, the RPS (with or without lymph nodes) is accessioned in the usual fashion.
• The RPS should be fixed in neutral buffered formalin (minimum 10:1 ratio) for a minimum of 18-24 hours prior to sectioning. A microwave-assisted technique may be used to reduce fixation time.
• The prostate gland should be weighed and measured in three dimensions; seminal vesicles should be measured; accompanying lymph node specimens should also be measured and a record made of the number and size of grossly identified nodes.
• The outer aspects of the RPS should be carefully inked to identify the surgical margins,prior to tissue banking.
• After appropriate fixation and inking, the distal apical segment is transected and then serially sectioned, perpendicular to the inked surface. An en face (shave) technique is to be discouraged at the apex, as this approach can result in false-positive margin interpretation.
• The basal (bladder neck) aspect is commonly doughnut shaped and irregular. It is transected from the main specimen and should also be submitted in a perpendicular fashion to minimize the possibility of a false-positive margin at this location.
• The intervening transverse sections can be either totally or subtotally submitted using regular-sized blocks. The submission protocol should be documented with an appropriate diagramatic or written block legend.
• For subtotal submissions, a systematic approach to include the posterolateral peripheral zone should be used.
• All lymph nodes accompanying the RPS should be submitted for histological analysis. It is not necessary to submit all perinodal fat, although it is often difficult to distinguish between adipose tissue and fatty lymph nodes.
• The full CAP checklist and protocol for RP are available at
http://www.cap.org/apps/docs/cancer_protocols/2006/prostate06_pw.pdf

http://www.cancercare.on.ca/pdf/pebc17-3s.pdf

Synoptic reporting of cancer

Synoptic reporting of cancer:

Research studies during the 1990s revealed a significant amount of variation in the content of cancer-related pathology reports.Although the reports contained similar information, they could not be used toaccurately compare cases, treatment options, or clinical outcomes. Variability was mainly due to dictated free-text that contained transcription errors, insufficient and sometimes omitted clinical data. In response to these findings, the CAP Cancer Committee developed tumor site specific checklists for pathologists to use as a common framework for cancer reporting.

The synoptic section of the report uses standardized content and definitions in a coherent, clinically relevant and consistent way. This format allows the pathologist’s findings to be efficiently and effectively used in patient diagnosis, prognosis, and treatment. The use of standardized reporting has applicability in all areas of medicine to improve patient clinical documentation and to aggregate data across different platforms.Sharing standardized cancer information will help to win the war on cancer by providing comparable tumor data and treatment outcomes that can be used to support initiatives in cancer research and in public health.

What are the Cancer Checklists?
The CAP Cancer Checklists are a set of standardized, evidence-based, “scientifically validated” protocols for the 60 most commonly reported forms of cancer.Checklists are developed by the CAP Cancer Committee, a team of pathology experts and liaisons from other highly recognized cancer organizations. The checklists consist of data elements structured as a set of questions and prospective answers with reference information regarding the intended use and meaning of checklist elements. The cancer checklists are available in doc and pdf file versions on the CAP Web site at www.cap.org , and in an electronic format consistent with existing international standards for incorporation into existing information systems. The CAP cancer checklists form a library of best practices in pathology reporting for cancer specimen data.