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Question.
Based on the initial images, what is your first impression?
Based on the initial images, what is your first impression?
#GUPath twitter brain trust. Posting for a colleague.
37yo man with a renal mass.
Pos for PAX8, keratin. Neg for NE markers, GATA, WT1 and everything else.
We are stumped. Thoughts? Anyone seen something like this before? We thought of adult Wilms’s but IHC doesn’t support.
37yo man with a renal mass.
Pos for PAX8, keratin. Neg for NE markers, GATA, WT1 and everything else.
We are stumped. Thoughts? Anyone seen something like this before? We thought of adult Wilms’s but IHC doesn’t support.
@Williamson_SR @Kiril_T_Can @johncheville @rovingatuscap @MichelleDunno17 @FionaMacPath @daniel_berney #GUPath
Tumor is primary to the kidney. He’s older and PAX8 +++ so we didn’t think this was teratoma. I did consider it briefly.
Pelvic biopsy on a 20yo boy. Clinically presented with a large mass inseparable from the bladder and widespread mets. Radiology strongly favored a UCA and patient was transferred to the GU service. Continued 👇#GUpath
The young age of the pt and the morphology didn't make sense for UCa to me. D/D considerations included
NET & SBRCT.
I did a limited panel. Pos stains: Ker, desmin, CD99 Neg stains: CG, Syn, GATA
Continued: 👇#GUPath
NET & SBRCT.
I did a limited panel. Pos stains: Ker, desmin, CD99 Neg stains: CG, Syn, GATA
Continued: 👇#GUPath
Diagnosis: Diagnosis: Desmoplastic small round cell tumor (pending FISH conf).
Lessons learned:
1. Trust your instincts, esp if the clinical scenario isn't making sense
2. I am glad my Soft Tissue Pathology fellowship from 12 years ago hasn't completely failed me #GUPath
Lessons learned:
1. Trust your instincts, esp if the clinical scenario isn't making sense
2. I am glad my Soft Tissue Pathology fellowship from 12 years ago hasn't completely failed me #GUPath
Yesterday was a fun day on #GUPath. PGY1s, how many of these renal cell tumors can you name?
The oncocytic one is strongly and diffusely CK7+. What does this help differentiate it from?
Oncocytoma. Both chromophobe and oncocytoma are associated with Birt-Hogg-Dubé syndrome, an AD syndrome where you get papular fibrofolliculomas of face, neck, and trunk as well as multiple oncocytic RCCs. It is associated with 17p12q11 abnormality involving folliculin protein.
#GUpath
So many great tutorials lately, I’ll contribute this review on some prostate cancer basics.
Prostate cancer 101
Random section from a prostatectomy for cancer.
@slusagar @TheKarenPinto @Williamson_SR @ariella8 @MELanocyteMD @TedFarMD @mhassanaimc
So many great tutorials lately, I’ll contribute this review on some prostate cancer basics.
Prostate cancer 101
Random section from a prostatectomy for cancer.
@slusagar @TheKarenPinto @Williamson_SR @ariella8 @MELanocyteMD @TedFarMD @mhassanaimc
2. Slightly higher power, ill address each of the circled areas.
3. Orange box: Atrophy. Make a mental note of the lobulated architecture (red circles), a benign feature.
Bladder tumor in a 60 y. Stains and D/D below 👇#GUpath
D/D considerations of a tumor with glandular features include:
1. UCa with glandular features
2. Urachal carcinoma
3. Clear cell adenocarcinoma
4. Metastasis
This case was PAX8+ CK7+ HNF1B+(pics) GATA3-
Diagnosis: Clear cell adenocarcinoma #GUPath
Continued 👇
1. UCa with glandular features
2. Urachal carcinoma
3. Clear cell adenocarcinoma
4. Metastasis
This case was PAX8+ CK7+ HNF1B+(pics) GATA3-
Diagnosis: Clear cell adenocarcinoma #GUPath
Continued 👇
Always be suspicious of glandular bladder tumors , esp if there isn't a typical UCa component present.
CC AdenoCa can occur anywhere in the GU tract with a propensity for the urethra and diverticulae.
Stains can help distinguish from urachal Ca. History is important #GUPath
CC AdenoCa can occur anywhere in the GU tract with a propensity for the urethra and diverticulae.
Stains can help distinguish from urachal Ca. History is important #GUPath
History: Female, 50-ish, presented with hematuria.
Cystoscopy: Congested mucosa with bleeding ulcers
Biopsy from urinary bladder lesion
#pathology #GUPath
Cystoscopy: Congested mucosa with bleeding ulcers
Biopsy from urinary bladder lesion
#pathology #GUPath
What should I do?
I should call the surgeon
“Did the patient have urinary bladder cancer before?”
NO
Patient had cervix cancer, a year back
“Did the patient have urinary bladder cancer before?”
NO
Patient had cervix cancer, a year back
Renal bx from a woman in her late 50s, with a renal mass and metastasis. This biopsy is from the kidney. This was a highly infiltrative, high grade tumor with a desmoplastic background. Continued 👇 #GUpath
The referring institute reported + PAX8, CK7, - GATA3, CK20, TTF1. O/S diagnosis was collecting duct carcinoma.
Upon review by us, we realized that the pt was AA and ordered an INI-1 which was negative.
Diagnosis: Renal medullary carcinoma (confirmed by Hb electophoresis) 👇
Upon review by us, we realized that the pt was AA and ordered an INI-1 which was negative.
Diagnosis: Renal medullary carcinoma (confirmed by Hb electophoresis) 👇
True CDC of the kidney is extremely rare and is a diagnosis of exclusion. All tumors that look like a high grade adenoca, automatically get an INI-1. (I always exclude Uca and mets.)
RMC is usually a disease in younger pts, but can present at any age. #GUpath @PavlosMsaouel 👇
RMC is usually a disease in younger pts, but can present at any age. #GUpath @PavlosMsaouel 👇
Continuing yesterdays theme. Renal bx from a mass in a 55 yo. This one showed more stroma and the nuclei lining the cysts were less "ugly". Continued 👇#GUpath
Mass was resected and was <4 cm and well circumscribed. 👇
Always run an FH stain (pic) on anything that looks tubulocystic . This was also positive for CK7, P504S and neg for CAIX and CD117.
Final diagnosis: Tubulocystic RCC
Continued 👇
Final diagnosis: Tubulocystic RCC
Continued 👇
Rib mass in a young male with a renal mass (not biopsied). Morphology was entirely tubulocystic. Thread continued below. 👇 #GUpath
This is what the follow up resection looked like. I received this a few years ago, before we had the FH stain in house. Given the extensive tubulocystic morphology and high grade nuclei, I asked the clinician to test the pt for an FH gene mutation (he was + for the mutation). 👇
Final diagnosis: HLRCC.
Tumors may be extensively tubulocystic (TC), especially on bx. These are far more common (in my practice) than true TC RCC's. I run the FH stain on all RCCs with TC features.
Bx was signed out as RCC with TC features, clinically exclude HLRCC. #GUpath
Tumors may be extensively tubulocystic (TC), especially on bx. These are far more common (in my practice) than true TC RCC's. I run the FH stain on all RCCs with TC features.
Bx was signed out as RCC with TC features, clinically exclude HLRCC. #GUpath
Incidental renal mass. Stains and diagnosis 👇#GUpath
PAX8 (highlighting epithelium) and HMB45 (stains stromal component).
Diagnosis: Angiomyolipoma with epithelial cysts (AMLEC) ER highlights condensed subepithelial stroma below the cyst epithelium. Cystic change may be very focal or extensive. Pay attention, especially on biopsies, for a cyst lining. #GUpath
Histologic features of RCC, status post immunotherapy.
These features include extensive lymphoplasmacytic infiltrate, hemosiderin deposition, hylanization and fibrosis. Continued 👇 #GUpath
These features include extensive lymphoplasmacytic infiltrate, hemosiderin deposition, hylanization and fibrosis. Continued 👇 #GUpath
As in this example, tumor can be obscured by inflammation and need a CK (pic) to make a diagnosis. Also pictured is CD10 . Continued 👇 #GUpath
In my practice, I give an estimate of residual tumor burden, which is a more accurate assessment of tumor response as the gross size may stay the same (or even increase- called "pseudoprogression") due to the intense inflammatory infiltrate, which can mimic a mass. #GUpath
Renal tumor in a 19 year old. Stains and diagnosis 👇 #GUpath
CD117 and Synaptophysin (pictures) +. PAX8 -
CD34+ (pic) keratin -
I present to you, the single best case of my life.
36 yo woman with a kidney tumor. This was sent to me in consultation by a very smart friend in private practice because she thought it "looked funny". Thread continues 👇#GUpath
36 yo woman with a kidney tumor. This was sent to me in consultation by a very smart friend in private practice because she thought it "looked funny". Thread continues 👇#GUpath
All keratins negative, PAX8 (pic), CAIX (pic) and S100 + ki-67=10% . Only very rare mitoses identified, which was also odd.
Still funny. I had a diagnosis in mind, so I ran more stains. All melanocytic markers and TFE3 -. Inhibin (pic1) strongly positive. CD31 (pic2) positive in vascular network. Of note, no tumors anywhere else in the body.
I had a colleague from private practice ask me if I ever make a diagnosis of RCC with leiomyomatous stroma (RCCLMS). I thought this would be a good time to share an example. Continued 👇
An excellent summary of the molecular findings was published this mth in AJSP by @rajalbshah & @Kiril_T_Can suggests that these are unique tumors that harbor mutations in the TSC, MTOR and ELOC (TCEB) genes and are distinct CCRCC. Diffuse expression of CK7 is key.
These are sporadic counterparts of similar tumors seen in the setting of TSC. I have seen several cases like this and there was not a consensus on what these should be classified as. I like this terminology and will be using this in my practice. cc: @SurenaMatinMD
Painless hemiscrotal mass in a child, complex hydrocele on ultrasound.
Testis mass + smear... Fight!
#pedipath #gupath #cytopath
Testis mass + smear... Fight!
#pedipath #gupath #cytopath
Rhabdomyosarcoma is indeed the top-level diagnosis... but more importantly, what type??
Note: several H&E patterns here that correspond nicely to the patterns on cytology.
#pedipath #gupath #pathology
Note: several H&E patterns here that correspond nicely to the patterns on cytology.
#pedipath #gupath #pathology
Note the multiple patterns here - and see how they relate to myogenin staining.
This is an uncommon example of mixed-histology rhabdomyosarcoma.
Classic Embryonal - variable myogenin
Dense Emb/Solid Alveolar - strong, diffuse myogenin
Sclerosing - Weak/absent myogenin
#pedipath
This is an uncommon example of mixed-histology rhabdomyosarcoma.
Classic Embryonal - variable myogenin
Dense Emb/Solid Alveolar - strong, diffuse myogenin
Sclerosing - Weak/absent myogenin
#pedipath
#GUpath puzzler time!
(for those of you familiar with this case, please keep 🤫!)
middle aged M found to have bilateral breast enlargement. Work-up revealed elevated serum PSA. MRI-guided prostate biopsy done of abnormal area seen on imaging.
🔬?🤔?
(for those of you familiar with this case, please keep 🤫!)
middle aged M found to have bilateral breast enlargement. Work-up revealed elevated serum PSA. MRI-guided prostate biopsy done of abnormal area seen on imaging.
🔬?🤔?
my DDx:
▶️Gleason 5+5 prostatic adenocarcinoma (for all new bx cases, I always do confirmatory prostate #IHCpath)
▶️plasmacytoid urothelial carcinoma
▶️signet ring GI tract adenocarcinoma
▶️metastatic lobular carcinoma
▶️Gleason 5+5 prostatic adenocarcinoma (for all new bx cases, I always do confirmatory prostate #IHCpath)
▶️plasmacytoid urothelial carcinoma
▶️signet ring GI tract adenocarcinoma
▶️metastatic lobular carcinoma
not shown but negative were:
NKX3.1/PSAP, CK20, uroplakin2
NKX3.1/PSAP, CK20, uroplakin2
