Pathology Week 6 p18-35

Result of QA Procedures: - 2009: 23% GYN cases re-screened - 62 Negative cases reclassified: ASC-US+ Epithelial Cell Abnormalities: Squamous Cell - Atypical squamous cells, of undetermined significance (ASC-US) - Atypical squamous cell, cannot exclude HSIL (ASC-H) ASCUS: Cytologyic Follow-Up - 643 Study patients - 137 SIL on cytology follow-up (11.7%) - 46 HSIL on cytology follow-up (6.0%) ASCUS Follow-Up Literature Review: Biopsy Immediately Following ASCUS Daignosis: - 15 studies, 3414 patients - 36% SIL rate (range, 16-60%) - 12% HSIL rate (range, 4-25%)

ASCUS Follow-Up Conclusions: - Among ASCUS patients followed for up to 9 years, 20% develop only low grade SIL or mild dysplasia and 10% develop HSIL or moderate or severe dysplasia - ASCUS should be retained as a diagnostic category since it identifies a significant percentage of patients who are at an increased risk for the development of cervical dysplasia. Age of DNA Testing: - The sensitivity of HPV DNA testing for the detection of biopsy-confirmed CIN 2,3, in women w/ASCUS is 83%-100% and is higher than the sensitivity or a single repeat cytologic test. - Between 31% and 60% of all patients w/ASCUS will have high risk HPV types.

Case: 37F; Conventional smear:

Cytologic Diagnosis: Adenocarcinoma in situ (AIS). Cervical Cone Biopsy:

Histologic Diagnosis: - Invasive endocervical adenocarcinoma - 5mm depth - 9mm width - Close to margins (.1mm)

Case: 73F; Postmenopausal bleeding; Conventional smear:

Final Histologic Diagnosis: Endometrial adenocarcinoma. - Clear cell adenocarcinoma - 1.0cm - FIGO grade 3/3 - Invasion into superficial half of myometrium ThinPrep AGC Follow-Up Study: - AGC diagnosis ignored in 41% - 32% of HP Dx significant - 95% >35 - 17 malignancies - All malignancies in older age group - 15 endometrial primary - 2 metastases

Points to Remember: - Lab test does not replace careful clinical exam - Must perform colposcopy and biopsy cervical lesions - Biopsy suspicious cervical lesions - Colposcopy may miss endocervical lesions

Bronchogenic Carcinoma: - #1 cancer in US – accounts for greatest number of cancer deaths - 80% of all cancers can be diagnosed preoperatively by cytology - minimum of false positives

Sputum Cytology Results: - sputum detection rate - single sputum detection rate = 30% - better for central tumors - better for primary tumors - false positive rate transudates - % malignant = 27.6 - most metastases: - breast 33% - lung 20% - colon 20% - lymphoma 7% Urinary Cytology Indications: - suspected bladder, ureteral, or renal pelvis cancer - history of treated TCC - persistent symptoms of bladder irritation - occupational history - suspected renal adenocarcinoma Urinary Cytology Types of Specimens: - voided urine good (hydrate patient) - bladder wash good - cytoscopic urine good - first AM urine no good - catherterized urine no good - lavage not always better than voided urine Other Sites Amenable to Cytologic Evaluation: GIT, CSF, oral cavity, larynx, nasopharynx/paranasal sinuses, eye. GIT: All areas accessible to brushing, washing, aspiration - biliary tree - pancreatic duct - esophagus Regenerating cells near ulcers can cause diagnostic confusion. Japan: screened 200,000 gastric cancers, detected low stage.

CSF: -

lumbar or cisternal puncture send to lab immediately If lab closed: refrigerate, add equal volume balanced salt solution + 20% albumin

Fine Needle Aspiration (FNA) Cytology: - Superficial (palpable) masses - Deep-seated lesions FNA Cytology Requirements: - Cytopathologist - Properly trained radiologist - team approach - as much clinical data as possible FNA Cytology Value: - definitive diagnosis - documentation of metastases - evacuation of cysts - “triage” FNA Advantages: - relatively atraumatic - accurate - rapid - cost-effective FNA Cytology Cytomorphologic Evaluation: - nucleus - cytoplasm - entire cell - intercellular relationships - smear background (video on fine needle aspiration cytology) Entities Diagnosable by FNA Cytology of Superficial (Palpable) Lesions – Partial List Breast - infiltrating duct carcinoma - intraductal carcinoma - medullary carcinoma - fibroadenoma - cystosarcoma phylloides - fibrocystic disease - gynecomastia - mastitis (acute/chronic) Lymph Node - metastatic carcinoma - metastatic melanoma - malignant lymphoma - Hodgkin’s disease - reactive lymphoid hyperplasia Salivary Gland - pleomorphic adenoma - Warthin’s tumor - adenoid cystic carcinoma - mucoepidermoid carcinoma - chronic sialadenitis

Thyroid Gland - papillary carcinoma - follicular lesion - Hurthle cell lesion - nodular goitre - Hashimoto’s thyroiditis - lymphocytic thyroiditis - malignant lymphoma Soft Tissue - metastatic carcinoma - metastatic melanoma - benign fibroblastic lesion - malignant fibrous histiocytoma - leiomyomal/leiomyosarcoma - lipomal/liposarcoma - sarcoma, not otherwise specified Lung - all varieties of carcinoma - mesothelioma - pulmonary hamartoma - malignant lymphoma - inflammatory/infectious diseases Pleura - adenocarcinoma - mesothelioma Mediastinum - thymoma - malignant lymphoma - germ cell tumors Liver - hepatocellular carcinoma - leiomyosarcoma - angiosarcoma/hemangioma - abscess Pancreas - pancreatic carcinoma - islet cell tumor - chronic pancreatitis

Kidney - renal cell carcinoma - transitional cell carcinoma - angiomyolipoma - oncocytoma Adrenal - adrenal cortical adenoma - adrenal cortical carcinoma - pheochromocytoma Retroperitoneum - malignant lymphoma - sarcoma Deep Seated Lesions - fluoroscopy - ultrasound - CT - endoscopic FNA Ancillary Studies - Electron microscopy - Immunoperoxidase staining: direct smears, cytospin preparations - Flow cytometry: cell surface marker analysis, DNA analysis FNA Complications (11,700 patients) - mortality rate 0.008% - total complication rate 0.55% - major complication rate 0.05% - minor complication rate 0.49% - Major complications: biliary peritonitis (2), tumor seeding (1), intrahepatic hematoma (1), peritonitis (1) - Other complications: needle tract implantation (papillary ca, thyroid), needle tract seeding (pancreatic ca), cutaneous seeding (pancreatic ca), necrosis (Hurthle cell tumor), acute thyroid swelling, massive bleeding (liver)

Pathology of Breast

Fri. 09/24/10

Signs & Symptoms: • Mass/lump – Fibrocystic disease – Fat necrosis – will see giant cells and foamy macrophages. – Fibroadenoma and related lesions – Carcinoma • Nipple discharge ?bloody (Non-bloody = benign) – Papilloma – Carcinoma • Mammographic abnormality – Microcalcifications • Fibrocystic disease • Carcinoma, particularly DCIS – Architectural distortion • Fibrocystic disease • Carcinoma, particularly lobular

Test q: A 40y/o woman who was recently in an automobile accident noticed a firm mass in the upper-outer quadrant of her right breast. A mammogram 2mo ago was normal. Which microscopic description is most consistent w/the clinical history? Giant cell and foamy macrophages. Test q: A 30y/o woman sustained a traumatic blow to her right breast. Initially, there was a 3cm contusion that resolved within 3wk, but she then felt a firm lump that persisted below the site of the bruise 1mo later. What is the most likely diagnosis for this lump? Fat necrosis Test q: A 36y/o woman has noticed a bloody discharge from the nipple of her right breast for the past 3 days. On phys exam, the skin of the breasts appears normal, and no masses are palpable. There is no axillary lymphadenopathy. The patient has regular menstrual cycles and is using oral contraceptives. Excisional biopsy is most likely to show which of the following lesions in her right breast? Intraductal papilloma Test q: Histologic features seen in breast ducts that are worrisome for breast cancer are: cell uniformity and microcalcification

Normal breast: fat + breast tissue • Ducts • Terminal ducts lobular units (TDLUs) – Lined by 2 layers of cells • Epithelial (luminal) • Myoepithelial (basal) - surrounded by a basement membrane • Benign diseases have both cells types • Malignant lesions have only one. Fibrocystic changes: • Terminology--fibrocystic changes, fibrocystic disease, chronic cystic mastitis, periductal mastitis, mammary dysplasia, cystic mastalgia • Three dominant morphologic patterns – Cystic formation and fibrosis – Epithelial hyperplasia – Sclerosing adenosis • Demographics – Microscopically extremely common, present to some degree in 60 to 90% of breasts in routine autopsies – Everyone has fibrocystic change to some extent • Etiology: Variable end-organ response to hormonal stimuli • Cysts and fibrosis – Mass and or Microcalcifications (phosphate) – Unopened cysts are brown to blue (blue-dome cysts) – Very common type - characterized by an increase in fibrous stroma associated with dilatation of ducts and formation of cysts of various sizes. – Gross cysts > than 3 mm, micro cysts smaller – Cysts often lined by large polygonal cells with abundant eosinophilic cytoplasm--so called apocrine metaplasia. Cuboidal epithelial cells. Fibrocystic disease: sclerosing adenosis w/calcification Arrow shows a focus of microcalcification. Test q: A 27y/o woman feels a lump in her right breast. She has normal menstrual cycles, she is G3, P3, and her last child was born 5yr ago. The physician palpates a 2cm, irregular, firm area beneath the lateral edge of the areola. The mass is not painful and does not feel firm. There are no lesions of the overlying skin and no axillary lymphadenopathy. A biopsy specimen shows microscopic evidence of an increased number of ducts, which are compressed because of proliferation of fibrous connective tissue. Dilated ducts w/apocrine metaplasia also are present. What is the most likely diagnosis? Fibrocystic disease

Above: normal breast. Myoepithelial layer – periphery, between epithelial layer and basement membrane.

Portions of cytoplasm are chewed off. Usually always benign. Apocrine metaplasia – no longer have apocrine secretion. Fibrocystic changes: • Epithelial hyperplasia  – (a little worse than cyst formation) – commonly coexists with fibrosis, cysts, adenosis – Microscopically, proliferation causes an increase in the layers of the duct-lining epithelium beyond the usual double layer – Mild, moderate or florid – The presence of architectural and/or cellular atypia warrants a diagnosis of ‘atypical hyperplasia’ Figure: Duct lobular units filled w/a number of cells –  polyclonal in origin. Lumen is irregular. Normal because its association w/malignancy is not strong. Sclerosing adenosis – destruction of normal lobular architecture. Increased number of glands. • Sclerosis = fibrosis; Adenosis = # of glands • Clinical- hard cartilaginous consistency that begins to approximate that found in breast cancer. • Microcalcifications frequent • Proliferation of both epithelial and myoepithelial cells • Minimal or no increased risk for cancer. Figure: sclerosing adenosis  Glands are not clear. Increased number of epithelial cells. Sclerosing adenosis is associated w/calcifications. Clinical significance of fibrocystic changes: • Produce lesions mimicking carcinoma – the following features favor benign disease: bilaterality, multiple nodules, pain prior to menstruation, type of microcalcifications • Some histologic types may predispose or are a marker for the subsequent development of carcinoma – especially those with epithelial hyperplasia (Proliferative and non-proliferative types)

Types of fibrocystic change and risk of subsequent carcinoma: • No increased risk: fibrosis, cystic changes, apocrine metaplasia, sclerosing adenosis, mild hyperplasia • Slightly increased risk, 1.5 to 2 times: hyperplasia moderate to florid, ductal papillomatosis • Significantly increased risk, 5 times: atypical hyperplasia, ductal or lobular with ductal involvement. • A family history of breast cancer increase the risk in all categories—e.g., to about 10-fold with atypical hyperplasia. DCIS = 10x risk Test q: The change within the spectrum of fibrocystic disease that is associated w/the greatest risks for breast cancer is: atypical hyperplasia

Breast carcinoma • Breast carcinoma causes some 20% of cancer deaths among females. • 43,000 deaths in US • Age adjusted death rate about 27 per 100,000 • 1 of 11 women in US have a lifetime risk for developing the disease (incidence) Breast carcinoma: Incidence and epidemiology: • Geographic influences: 5 times more common in US than Japan and Taiwan • Genetic predisposition: Well defined. The magnitude of risk is in proportion to number of close relatives with breast cancer and age when cancer occurred in relatives. The younger the age of relatives and more bilateral cancers the greater the genetic predisposition. Uncommon families with apparent autosomal dominant transmission and familial association of breast and ovarian carcinomas. • Increasing age: Uncommon before age 20, but then a steady rise to the time of menopause, followed by a slower rise throughout life • Length of reproductive life: risk increases with early menarche and late menopause (exposure of breast to increased estrogens) • Parity: More frequent in nulliparous than in multiparous women • Age at first child: Increase risk when over 30 – Early pregnancy (full-term, not abortion) is protective • Obesity: Increased risk attributed to synthesis of estrogens in fat depots • Exogenous estrogens: Still controversial • Oral contraceptives/Abortion: No clear-cut increased risk • Fibrocystic changes with atypical epithelial hyperplasia: increased risk • Carcinoma of the contralateral breast or endometrium: increased risk • Diet and environmental agents: high lipid diet and moderate alcohol consumption increase risk slightly (only w/alcohol and NO folate) Familial Breast Cancer: • BRCA1 – more aggressive tumors – Younger women, high grade tumors, ER• BRCA2 – no specific association – Relatively older, low grade (lobular) tumors • BRCA1 and 2 – common in Ashkenazi Jews. Involve DNA repair and scaffolding. • Others – p53, Chk2, ATM, pTEN – do not know significance – unknown Carcinoma in-situ (pre-disposing) • Types of ductal carcinoma in-situ (DCIS): – Based on ARCHITECTURE (old) – not used much anymore. • Solid • Comedo – necrosis – On cut section central necrosis leads to easily extruded by slight pressure giving rise the term ‘comedocarcinoma’ • Cribriform • Papillary • Micropapillary • Usual variants: Apocrine, ‘Clinging’, Clear cell • Some have all of the above, so we use nuclear grade. Better to diagnose w/this. – Based on NUCLEAR GRADE – constant in any lesion. • Low • Intermediate • High

Test q: Genes known to have mutations responsible for development of breast neoplasms include all the following EXCEPT: Abl (Other choices: BRCA1, P53, Heu/2, BRCA2)

Above: Duct filled w/monotonous population of cells, can also have foci of calcifications.

Above: Cribriform – c-shaped. “Ducts in a duct.”

Above: Comedo – name comes from zit. When you squeeze it, pus comes out.

Test q: A 63y/o woman feels a small lump in her right breast. The physician palpates a firm area that has a cordlike feel. No lesions of the overlying skin are present, and there is no axillary lymphadenopathy. A mammogram shows a density that contains microcalcifications. An excisional biopsy specimen contains soft, white material that is extruded from small ducts when pressure is applied. Microscopic exam shows ducts that contain large, atypical cells in a cribriform pattern. What is the most likely diagnosis? Comedocarcinoma

Lobular carcinoma in situ: • proliferation in terminal ducts and/or ductules of loosely cohesive cells • risk factor for the subsequent development of either infiltrating ductal or lobular carcinoma, 9x risk - Not invasive, but associated with ↑ risk.

Figure: LCIS  Monotonous cells – lack of pleomorphisms. See spaces without cells. Ducts filled with solid masses of cells.

Paget’s Disease: carcinoma cells going through ductal system and involving epidermis. • Specialized form of ductal carcinoma that arises in the main excretory ducts of the breast and extends to involve the skin of the nipple and areola. • Clinically, eczematoid changes occur in the nipple and areola (scaling and erythema) • Ductal carcinoma, with or without invasion, invariably antedates the skin change. • 30 to 40% of women have metastases at the time of surgery • Histologic hallmark of this entity is the involvement of the epidermis by malignant cells, referred to as Paget cells Test q: Paget’s disease of nipple is associated with: Invasive ductal carcinoma

Invasive Breast carcinoma: • Clinical presentation • Mass • Mammaographic abnormality – Microcalcifications – Architectural distortion • Nipple symptoms – Inversion or discharge • Approximately 50% arise in the upper outer quadrant; 10% in the remaining quadrants and 20% in the subareolar region

Above: Paget’s disease of the nipple. Local involvement of the skin. Tumor cells = lightly colored. Dermis is free of tumor. Tumor infiltrating to epidermis but is NOT an invasive cancer.

Test q: The most common location for ductal carcinoma in the breast is: Upper-Outer quadrant

Advanced or untreated cases: • Lympho-hematogenous spread – tumor spreads through lymphatics. Stage IV. – axillary and internal mammary lymph nodes – Distant metastases – usually to liver, lung, and bone. Brain metastases = lethal. • Adherent to the chest wall • extension to the skin (retraction and dimpling)

• dermal lymphatic involvement leads to skin thickening and lymphedema, – peau d’orange (orange peel) • Acute swelling, redness, and tenderness. Inflammatory carcinoma – poor prognosis.

Test q: Inflammatory carcinomas of the breast exhibit: lymphatic invasion by tumor Test q: The left breast of a 39y/o female is slightly enlarged compared w/the right. The skin overlying this breast is thickened, reddish-orange, and pitted. Mammography reveals a 3cm underlying density. A fine-needle aspirate of this mass reveals carcinoma. How is the gross appearance of the left breast best explained? Lymphatic obstruction.

Classification: • Molecular/Intrinsic – ER positive (luminal) – ER negative • Her-2 positive • Basal type • Histological – Ductal – 90% of cancers – Lobular – do not make glands, “Indian-filing”. Bilateral, high-stage (not detected). Intrinsic classification: – cDNA based – 100s of cases – ?Anatomic – not sure if anatomic is thought to be prognostic. – Also prognostic ER + = luminal A ER - = other luminals Luminal A = low grade tumor. Intrinsic Subtype Classifier: Significant Prognostic Information – – Luminal A pts had best OS & RFS – better prognosis. – Basal type patients had the worst – HER2 patients had an intermediate – Luminal B, though ER+, did significantly worse than Luminal A Infiltrating ductal carcinoma: • Grossly has a hard cartilaginous consistency and produces a grating sound when scraped. Dense fibrous stroma gives rise to the tumor a hard consistency and thus have been called ‘scirrhous carcinoma’ • Grading (Scarff-Bloom-Richardson) – Nottingham. – Tubule formation – more = better – Nuclear grade – less = better (nuclear polymorphism) – Mitotic activity – less = better • Based on these parameters graded as I, II or III Variants of ductal carcinoma: • Good prognosis – Tubular carcinoma – Mucinous carcinoma – Medullary carcinoma – Adenoid cystic carcinoma • Bad Prognosis – Metaplastic carcinoma – squamous cell carcinoma – Carcinoma with osteoclast-like giant cells – Apocrine carcinoma

Figure: Infiltrating carcinoma  Breast cancer – use ink to see where the tumor is. Note stellate shape. Figure: infiltrating ductual carcinoma  Low grade tumor associated w/tubule formation. Desmoplastic stroma = scar. Note duct-like structures and desmoplastic stroma.

Test q: Which of the following breast cancers has the WORST prognosis? Invasive ductal carcinoma (Other choices: tubular carcinoma, medullary carcinoma, mucinous (colloid) carcinoma, and fibroadenoma. See “good prognosis” list above.)

Tubular carcinoma: • Low SBR grade – Typically grade I • Good prognosis • LN mets –uncommon • Systemic mets – very rare

Tubular carcinoma: Figure: Nuclear pleomorphism and mitotic activity is minimal. 100% of tumor is forming glands.

Colloid or mucinous (extracellular mucin) carcinoma: – This variant of ductal carcinoma tends to occur in older women and grows slowly over years. – Grossly the tumor is extremely soft and the consistency and appearance of pale gray-blue gelatin – Histologically, tumors is composed of large pools of extracellular mucin that dissects and extends into contiguous tissue spaces and planes of cleavage. ‘Floating’ within this mucin are small islands and isolated neoplastic cells, sometimes forming glands. – Tumors may be mixed and composed of mucinous and nonmucinous (typical ductal) elements – Survival rate is greater in pure colloid carcinoma than in the usual type infiltrating duct carcinoma and lymph node metastases are infrequent Invasive lobular carcinoma (Think – INDIAN FILING) – WHO definition “composed of uniform cells resembling those of lobular carcinoma in situ and usually having a low mitotic rate.” – The cells grow typically in a single-file, linear arrangement, or appear individually embedded in fibrous tissue. Targetoid growth pattern and identification of remnants of lobular carcinoma in situ aid in the diagnosis. – Signet-ring cells may be seen – not associated w/a bad prognosis. Above: mucinous carcinoma. A lot of mucin, so bigger and diagnosed early. Clinical features of lobular carcinoma: – Lobular carcinoma comprises 3 to 14% of invasive carcinomas depending on the criteria involved – Grossly, mass is rubbery with ill-defined margins – Not prone to form calcifications – Relatively high frequency of bilateral & multicentric carcinoma--6 to 28% prior or concurrent contralateral carcinoma Pathologic features of lobular carcinoma: – Firm, rubbery to hard tumor with irregular borders, though may not be visibly abnormal or only slightly firm to palpation – Microscopic findings “the infiltrating portions of lobular carcinoma typically reveal thread-like strands of tumor cells rather loosely dispersed through out a fibrous stroma.” – So-called “Indian-file pattern” and “targetoid” growth patterns-- the latter is represented by concentric rings about normal ducts – “Small or medium-sized” cells exhibiting relatively little nuclear irregularity. – “Central mucoid globules” helpful diagnostic feature.

INDIAN FILING

TNM Staging – clinical • T-Primary tumor – based on size – T1: 2cm 5 cm – T4: any size with extension to skin/chest wall • N-Regional lymph nodes – NX: regional lymph nodes cannot be assessed – N0: No regional lymph node metastasis – N1: Metastasis to movable ipsilateral axillary nodes(s) – N2: Metastasis to ipsilateral axillary node(s) fixed to one another or to other structures – N3: Metastasis to ipsilateral internal mammary lymph nodes • M - Distant metastasis – MX: Presence of distant metastasis cannot be assessed – M0: No distant metastasis – M1: Distant metastasis (includes metastasis to supraclavicular lymph nodes Prognosis for invasive Breast carcinoma: 10-year disease free survival • 80% for T1N0 – 90% for T1N0 < 1 cm. • 70% for T2N0 • 60% for T3N0 Prognostic Factors:  Tumor Size: small tumors favorable prognosis  Lymph node involvement– 2/3rds have LN mets at the time of initial diagnosis – 5 year survival.  nearly 80% with no nodal involvement – 20 to 30% with negative nodes recur and die of disease within 10 years  50% with 1 to 3 nodes involved  21% with 4 or more nodes involved  Histological Grade  Lymphatic or Blood vessel invasion  Increase proliferative rate – thymidine and bromodeoxyuridine labeling – flow cytometry-S-phase fraction – Ki-67, PCNA (proliferating cell nuclear antigen, akacyclin)

Estrogen and progesterone receptors – therapeutic targets – 70% of tumors with positive ER regress after hormonal manipulation, whereas only 5% that are negative respond to these procedures – Tamoxifen – binds and inactivates estrogen receptors.  Her-2/neu (cerb B2) amplification – Herceptin – treatment that interferes w/the Her2/neu receptor 

Sarcomas of breast • Fibrosarcoma and malignant fibrous histocytoma • Liposarcoma • Osteosarcoma and chondrosarcoma • Postirradiation sarcoma • Hemangiopericytoma • Angiosarcoma – Post mastectomy angiosarcoma (Stewart-Treves syndrome)

Test q: A 38y/o female has a left breast lumpectomy. A mass which measures ½ cm in greatest diameter is excised as are two sentinel lymph nodes from the left axilla. The tumor consists of well-formed glands (tubules), exhibits no mitoses and has no nucleoli. The ductal adenocarcinoma is focally invasive and there is minimal desmoplasia. Both lymph nodes are negative for adenocarcinoma and there is no evidence of distant metastases in liver, lung, or bone. Special stains for Estrogen Receptor (ER) and Her-2 Neu are totally negative. The grade of this tumor is: I The stage of this tumor is: T1N0M0 The treatment plan for this patient will include: neither tamoxifen nor herceptin Test q: A mass is biopsied from the left breast of a 42y/o female. Invasive ductal carcinoma is present. All tumor cells are present as round glands. Mitoses are not seen and nucleoli are absent. This tumor can be described as: low grade. (Other choices: anaplastic, undifferentiated, hamartoma, or CIS) The tumor measures 1.1cm in diameter. Three sentinel lymph nodes are all negative for tumor. Distant metastases are not detected. The stage of this neoplasm is: T1N0M0 Test q: A 50y/o woman saw her physician after noticing a mass in the right breast. Physical exam showed a 2cm mass fixed to the underlying tissues and three firm, nontender, lymph nodes palpable in the right axilla. There was no family history of cancer. An excisional breast biopsy was performed, and microscopic exam showed a welldifferentiated ductal carcinoma. Over the next 6mo, additional lymph nodes became enlarged, and CT scans showed nodules in the lung, liver and brain. The patient died 9mo after diagnosis. Which of the following molecular abnormalities is most likely to be found in this setting? Amplification of the c-erb B2 (HER2) gene in breast cancer cells REPEATED x5!! (Once, answer was “Amplification of the ERBB2 (HER2) gene”) Test q: A mass was removed from the breast of a 46y/o female. The surgery performed was a lumpectomy w/axillary tail dissection (to look for metastatic disease in lymph nodes). The tumor measured 5.4cm in greatest diameter. Stromal invasion was extensive and desmoplasia was identified. 3-4 mitoses were present in every high-power field. Gland/tubule formation was not present and most of the tumor showed sheets and nests of undifferentiated malignant cells w/prominent nucleoli and irregular chromatin clumping. 15 lymph nodes were harvested from the axillary tail and 6/15 were positive for adenocarcinoma. 3 of the positive nodes were matted together and fixed (surrounded by fibrosis) to the surrounding soft tissue. Staining for estrogen receptors was entirely negative. Staining for Her2-Neu showed strongly positive cytoplasmic and membrane staining in 90% of the tumor cells. There was no clinical evidence of distant metastases. - An accurate grade for this tumor would be: Bloom and Richardson Grade III. - Additional treatment for this patient would include: Herceptin.

Mixed Epithelial and Stromal tumors: • Fibroadenoma – fibrous tissue and glandular tissue; in young women. – Benign – Glandular and stromal elements – Does not undergo malignant change • Phyllodes tumor – glandular and stromal – More cellular stroma than FA – Cellular pleomorphism, necrosis – May be benign or malignant • Benign morphology is poor predictor of behavior

Fibroadenoma:

Above: Can see circumscribed, firm white area in the fibroadenoma.

Above: “FA-cellular” view is a bit more fibrous, but not enough to be Phyllodes.

Phyllodes:

Bottom line in breast lesions: “IS IT BENIGN OR MALIGNANT?”

Above: Malignant Phyllodes. Stromal part = increased cellularity. Can have mitotic activity, pleomorphism, etc.

CONFERENCE: Tumor Invasion and Metastasis Neoplasms: Benign Non-invasive Non-metastatic

Fri. 09/24/10

Malignant Invasive Metastatic or non-metastatic

Exceptions to the Rule Benign tumors that may kill the patient: - Meningioma: expand, compress brain - Leiomyoma: do not mestastasize but expand – leiomyoma can erode blood vessels Malignant tumors without metastasis: - Glioblastoma multiforme - Basal cell carcinoma Malignant Tumor Properties - Penetration of the basement membrane - Invasion and destruction of surrounding tissue - Penetrate organ walls or fungate through the surface - Local invasion, like metastasis is a marker for malignancy - See Robbins Table 7-2 for benign vs malignant features

Benign: Smaller and well-circumscribed Malignant: spindle/irregular border

Metastasis - #1 marker of malignancy - Exceptions: gliomas (astrocytomas) of the brain and basal cell carcinomas of the skin RARELY metastasize; also, meningiomas LOCALLY invade skull bone, but do not metastasize and are considered benign. - (No lymphatics in the brain) - ** On board exams they sometimes substitute invasiveness for metastasis

Above: Malignant breast tissue. Can see irregular fingers sticking out. Not well circumscribed.

Cancer Statistics: - 90% of cancer deaths are due to metastases - 1/3 of breast and colon cancer patients have lymph node metastases at diagnosis - Frequency overall: liver, lung, bone (most frequent sites of metastasis) - #1 endocrine site: adrenal glands

Above: glioblastoma, highest grade. Do not metastasize, kills by expansion into brain tissue.

Figure: Metastatic melanoma Most malignant brain tumors are metastases from other sites.

Test q: The #1 cause of death in cancer patients is: Metastasis

Stage of tumors at diagnosis, listed by organ/site:

Above: subarachnoid spread in brain.

Pathways of Spread - Direct seeding of body cavities: peritoneal #1; also pleural, pericardial, subarachnoid, joint - Lymphatic spread: carcinoma> sarcoma; follows natural st drainage- breast cancer (Upper-Outer Quadrant) goes 1 to axillary nodes - Hematogenous spread (through blood): esp. sarcoma; also carcinoma; usually veins - Other: eg. Perineural spread – tumors can grow along the nerve Venous Drainage - Portal: liver - Caval: lungs - Paravertebral plexus: bypasses liver and lungs. Thyroid and prostate carcinomas metastasize to the vertebrae - Renal Cell CA: grows right along the bein. Invades renal vein and grows into the vena cava

Above: Breast cancer. Everything around nerve (pink) = glands growing in perineural space.

Sentinel LN Biopsy - “The first node in a regional lymphatic basin that receives lymph flow from the primary tumor”. If free of disease, do not remove more. - Dyes and radiolabeled tracers mark the node - Breast, colon and melanomas - In breast carcinomas it replaces a total dissection of the axillary lymph nodes and reduces morbidity (decreased risk for edema and angiosarcoma) Test q: A 58y/o woman diagnosed w/breast cancer in the left breast underwent a mastectomy w/axillary lymph node dissection. Postoperatively, she developed marked swelling of the left arm that has persisted for several months. The left arm is not tender or erythematous, and it is not painful to movement or touch. What alternative procedure might have prevented this complication? Sentinel lymph node biopsy.

ANGIOGENESIS - Tumors stimulate the growth of host blood vessels - Any tumor >2 mm in diameter must have a vascular supply - New vessels supply oxygen and nutrients and endothelial cells secrete growth factors Tumor Blood Vessels - Sprout new capillaries or “recruit” host endothelial cells - Tumor vessels are irregular and leaky due to high levels of VEGF - Tumor cells can also “mimic” endothelial cells (vasculogenic mimicry) Tumor-associated Angiogenic Factors: - VEGF (vascular endothelial growth factor) and bFGF (basic fibroblast growth factor) are made mostly by tumor cells but also by macrophages and stromal cells ANGIOGENIC SWITCH: - Angiogenesis is delayed; a minority of the cells become angiogenic - p53 inhibits angiogenesis by inducing production of thrombospondin-1 and down-regulating VEGF - Angiogenesis inhibitors made by tumor cells: thrombospondin-1; and angiostatin (from plasminogen), endostatin/tumstatin (collagen) - All are possible therapeutic targets! Test q: Which of the following situations favors tumor angiogenesis? Homozygous deletion of p53

Invasion and Metastasis: - Robbins Figure 7-42 - Cells break loose, enter and exit vessels and establish a 2° growth site - Rare malignant cells are successful at metastasis; Robbins Figure 7-43 Steps in Metastasis: • Detachment of cells from the primary tumor • Invasion of the surrounding tissue • Penetration to blood and lymphatic vessels • Arrest at target sites • Egression (extravasation) • Proliferation • Establishment of a new blood supply and tumor

Metastatic Cascade

Catenin – attach to cadherin. Under expression of cadherins, more likely to metastasize. Cadherins  cell attachment. Leads to breakdown of the matrix.

Invasion of the Extracellular Matrix (ECM) - Basement membrane - Interstitial connective tissue - Vessel basement membrane - Vessel basement membrane - Interstitial connective tissue Steps in the Invasion: - Detachment of cells (E-cadherin/catenins) - Attachment to the ECM (integrins attach to laminin/fibronectin) - Degradation of the ECM type IV collagen by serine, cysteine and matrix METALLOPROTEINASES (MMPs) - Migration of tumor cells (chemotaxis due to MMP cleavage products- growth factors released also - MMPs – need zinc to function. - Integrins – on the tumor cells, attach to laminin and fibronectin. Test q: A 61y/o woman has felt a lump in her breast for the past 2mo. On phys exam, there is a firm 2cm mass in the right breast. An excisional biopsy specimen of the mass shows carcinoma. Immunoperoxidase stains for matrix metalloproteinase-9 are performed on the microscopic tissue section and show pronounced cytoplasmic staining in the tumor cells. Which of the following characteristics is most likely to be predicted by this marker? Invasiveness.

Tumor Cells in Circulation: - They clump with each other, RBCs and platelets - Adhesion to endothelium (integrins-laminin-proteinases) – reattachment Test q: A 48y/o woman notices a lump in her left breast. On phys exam, the physician palpates a firm, non-movable, 2-cm mass in the upper outer quadrant of the left breast. There are enlarged, firm, nontender lymph nodes in the left axilla. A fine-needle aspiration biopsy is performed, and the cells present are consistent w/carcinoma. A mastectomy w/axillary lymph node dissection is performed, and carcinoma is present in two of eight axillary nodes. Which of the following factors is most likely responsible for the lymph node metastases? Increased laminin receptors on tumor cells REPEATED x2

Tumor Tropism - Different endothelial receptors in different organs - Different chemokine receptors on the tumor cells- eg. breast cancers express CXCR4 and CCR7 receptors and “matching” chemokines are at high levels in lung and lymph nodes. Chemokines influence where tumors will metastasize. - “unfertile soil” like skeletal muscle without receptors

Tumors exit blood vessels due to chemokine and chemokine receptor matches:

Metastases and Tropism: Primary Site and Histology - Clear cell carcinoma (kidney) - Cutaneous melanoma - Ocular melanoma - Adenocarcinomas of the GI tract - Follicular carcinoma, thyroid

Metastasis Genes: - Ezrin: a membrane component required for metastasis in osteosarcoma and rhabdomyosarcoma - Anti-metastasis genes: NM23

Organ Thyroid Small bowel/brain Liver Ovary (Kruckenberg tumor) Bone

Above: Ezrin. With this gene, tumors can metastasize.

Test q: A 48y/o woman notices a lump in her left breast. On phys exam, the physician palpates a firm, non-movable, 2cm mass in the upper outer quadrant of the left breast. There are enlarged, firm, nontender lymph nodes in the left axilla. A fine-needle aspiration biopsy is performed, and the cells present are consistent w/carcinoma. A mastectomy w/axillary lymph node dissection is performed, and carcinoma is present in two of eight axillary nodes. Which of the following factors is most likely responsible for the lymph node metastases? Overexpression of Ezrin in tumor cells.

Metastasis Oncogenes - SNAIL and TWIST (breast cancer) - Epithelial-to-mesenchymal transition - E-cadherin is down-regulated and vimentin is up-regulated Targeted Therapy: Signal-transduction Inhibitors - Block enzymes and Growth Factor Receptors - GLEEVEC (imatinib)- GIST (GI stromal tumor) and CML (abnormal tumor enzymes); - IRESSA (gefetinib)- non-small-cell lung cancer (EGFR) Drugs designed to attack rapidly diving cells 

Now trying to develop targeted drugs  Above: Tumor disappearance w/targeted therapy drug.

 Figure: Gleevec. Prevents phosphorylation of enzymes in tumors.

Target: Apoptosis Inducers - VELCADE- multiple myeloma (blocks proteasomes) - GENASENSE- leukemias and lymphomas (blocks BCL-2  restores apoptosis) - Bad to have low levels of normal p53 or high levels of abnormal p53. Target: Monoclonal Antibodies - Herceptin – invasive breast carcinomas (that show overexpression of HER-2-neu). Antibody against receptor. Target: Anti-angiogenesis – drugs have not been effective in humans. - Angiostatin (from plasminogen) - Endostatin (from collagen)

Figure: Tumor lining  more leaky, more TNF-α receptors, another possible drug target.

Pathology C603 Block I Review

Mon. and Tues. 09/27-09/28

Most of the inflammatory cells in this photo are: A. Eosinophils B. Lymphocytes C. Macrophages D. Neutrophils E. Plasma cells Abscesses are associated w/neutrophils. Answer: D, neutrophils The gross is a brain abscess and the microscopic shows a sheet of neutrophils. Some cells show 3 lobes while others show 1 or 2. Remember, you are looking at a 2-dimensional image, so you cannot identify every cell. TYPES OF NECROSIS: COAGULATIVE Infarcts LIQUIFACTIVE Abscess CASEATION TB Granuloma FAT (ENZYMIC) Pancreas and Breast Fat necrosis in pancreas – due to release of lipases and enzymes by the acinar glands. Fat necrosis in breast – sheets of macrophages, no enzymes involved. Above: granuloma – see giant cells (circled). Also, rim of T cells around the edge of the granuloma.

Above: pancreas – enzymic (fat) necrosis, saponification. Fatty acids broken down by enzymes  soap

Fibrous vs Fibrinous: Fibrosis/fibrous - Fibroblasts/collagen - Scar, desmoplasia, sclerosis - Permanent Dysplasia vs Desmoplasia Dysplasia - Premaligmant change, a precursor to cancer - Cervical dysplasia

Above: Fat Necrosis (L) and Normal Pancreas (R)

Fibrinous Fibrin/liquid protein Pericarditis and peritonitis Reversible, but may become fibrosis Desmoplasia - Fibrosis in reaction to invasive cancer - Invasive breast (nipple retraction); colon (apple core/napkin ring)

Sclerotic lesion = SCARRING lesion. Scarring associated w/an invasive tumor = desmoplasia

The classic shape of an infarct in the lung is: A. Circular B. Longitudinal C. Rectangular D. Inverted ellipse E. Inverted triangle D, wedge or triangle. Some infarcts are hemorrhagic (red) due to dual blood supply – lung, liver. Kill one blood supply, other supply continues to pump  hemorrhage. Most are pale. MI Dating: - 0 hours- normal myocardium (?thrombus in coronary) - 1-2 hours- “contraction bands”; myoglobin + (very sensitive but nonspecific) - 4 hours- loss of nuclei/cell death; Tn and CKMB + (both sens. and spec.) - 12-24 hours- migration of neutrophils; most muscle dead - 72 hours +/- 24 hours- macrophages migrate; - 5-10 days (ave. 7)- muscle is totally removed; macrophages fibroblasts and capillaries; no scar; Tn may remain elevated for 5-12 days - Several weeks- scar Test q: A patient suffers an MI and dies 30hr later in the coronary care unit. At autopsy, the infarcted area of the myocardium would most likely show: Coagulation necrosis w/neutrophil infiltration. Test q: A 76y/o woman suffers a massive MI and dies in cardiogenic shock 20hr after its onset. Microscopic exam of her infarcted myocardium would be expected to demonstrate which of the following? Coagulative necrosis w/few neutrophils. Test q: A 49y/o male suffers an acute MI. He is treated w/angioplasty. Serum troponin I becomes elevated, but his recovery is otherwise uneventful. He is discharged 5 days after onset of chest pain. At day 9 postMI, what would be the appearance of the infarcted area of the myocardium? Neutrophils, macrophages, and fibroblasts. Test q: A patient is found dead at home. The patient has a history of angina. At autopsy the CK-MB was normal and the cardiac Troponin I was elevated. The heart shows an area of coagulative necrosis with mixed inflammatory cells and evidence of new capillary growth and increased fibroblastic activity. The age of the infarct is approximately: 5 days – 1 week old. (Question was repeated with this answer: 3 days – 1 week old) Test q: (slightly diff from one above) A patient is found dead at home. Patient has a history of angina. At autopsy, the CK-MB was normal and the cardiac troponin I was elevated. The heart shows an area of coagulative necrosis with monocytes and evidence of new capillary growth and increased fibroblastic activity. The age of the infarct is approximately: 6-10 days old.