Kasus 2 - legeforeningen.no foreninger/Den norske...• HPV 16/33. Adenoid Basalt Carcinom •...
Transcript of Kasus 2 - legeforeningen.no foreninger/Den norske...• HPV 16/33. Adenoid Basalt Carcinom •...
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Kasus 2
73 år. Biopsi fra cervix. Øvrig sykehistorie ukjent
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Adenoid Basalt Carcinom
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Adenoid Basalt Carcinom
• Sjelden
• Eldre kvinner
• Meget god prognose– Adenoid basalt epiteliom?
– I ”ren” form
– Blandingssvulster
• Ingen klinisk tumor
• Oppdages tilfeldig
• CIN
• HPV 16/33
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Adenoid Basalt Carcinom
• Lobulær arkitektur
• Små, velavgrensede epiteliale øyer
• Basaloide celler– Mørke, runde/ovale kjerner
– Lite cytoplasma
– Perifer pallisadering
• Få mitoser, lite atypi
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Adenoid Basalt Carcinom
• Lobulær arkitektur
• Små, velavgrensede epiteliale øyer
• Basaloide celler– Mørke, runde/ovale kjerner
– Lite cytoplasma
– Perifer pallisadering
• Få mitoser, lite atypi
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Adenoid Basalt Carcinom
• Kjerteldifferensiering
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Adenoid Basalt Carcinom
• Kjerteldifferensiering
• Plateepiteldifferensiering– Eventuelt CIN123
– Fortsatt velavgrenset
– Tynn brem av basaloide celler
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Adenoid Basalt Carcinom
• Kjerteldifferensiering
• Plateepiteldifferensiering– Eventuelt CIN123
– Fortsatt velavgrenset
– Tynn brem av basaloide celler
• Immunhistokjemi– P16+
– P63+
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Adenoid Basalt Carcinom
• Vevsreaksjon?
• Cribriform vekst?
• Høygradige kjerner?
• Mange mitoser?
• Nekrose?
• Etc…
• Differensialdiagnostikk!!
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Differensialdiagnoser
• Adenoid basal hyperplasi– Overfladisk (<1 mm)
– Horisontal utbredelse
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Differensialdiagnoser
• Adenoid basal hyperplasi– Overfladisk (<1 mm)
– Horisontal utbredelse
• Adenoid cystisk carcinom– Solid variant !
– Høygradig malign
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Differensialdiagnoser
• Adenoid basal hyperplasi– Overfladisk (<1 mm)
– Horisontal utbredelse
• Adenoid cystisk carcinom– Solid variant !
– Høygradig malign
• Basaloid plateepitelcarcinom– Høygradig malign
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Differensialdiagnoser
• Adenoid basal hyperplasi– Overfladisk (<1 mm)
– Horisontal utbredelse
• Adenoid cystisk carcinom– Solid variant !
– Høygradig malign
• Basaloid plateepitelcarcinom– Høygradig malign
• Adenoskvamøst carcinom– Plate- og adenocarcinom
– Begge komponenter oftest høygradig maligne
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• Adenoid basalt carcinom 10
• Adenoid basalt epiteliom 1
• Plateepitelcarcinom 6
• Basaloid plateepitelcarcinom 3
• Lite differensiert carcinom 1
• Basalcellecarcinom 1
• Basoskvamøst carcinom 1
• Infiltrerende tumor, basalcellecarcinomlignende 1
Innsendte diagnoser
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Neste kasus…
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Kasus 3
76 år. Cervixbiopsi viste lite differensiert carcinom. Radikal hysterektomimed lymfeknutetoilette ble gjennomført. Snitt fra uterus.
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PAS
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SMA
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PAN-CK
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P16
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Adenoid Cystisk Carcinom
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Adenoid Cystisk Carcinom
• Sjelden
• Eldre kvinner
• ”Non-caucasians”
• Mucinøs ovarialtumor
• Aggressiv
– Ofte fjernmetastaser
– Høy mortalitet
• Tumor, blødning, etc…
• HR-HPV
• Tilsvarende tumor i spyttkjertel…?
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Adenoid Cystisk Carcinom
• WHO Classification of Tumours of Female ReproductiveOrgans -2014:– ”Definition: A tumour that resembles adenoid cystic carcinoma of the
salivary gland”
• WHO Classification of Tumours, Head and Neck Tumours –2005:– ”Definition: ACC is a basaloid tumour consisting of epithelial and
myoepithelial cells in variable morphologic configurations, includingtubular, cribriform and solid patterns. It has a relentless clinical courseand usually a fatal outcome”
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Adenoid Cystisk Carcinom
• WHO Classification of Tumours of Female ReproductiveOrgans -2014:– ”Definition: A tumour that resembles adenoid cystic carcinoma of the
salivary gland”
• WHO Classification of Tumours, Head and Neck Tumours –2005:– ”Definition: ACC is a basaloid tumour consisting of epithelial and
myoepithelial cells in variable morphologic configurations, includingtubular, cribriform and solid patterns. It has a relentless clinical courseand usually a fatal outcome”
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Adenoid Cystisk Carcinom
• Basaloide celler– Mørke, runde/ovale kjerner
– Lite cytoplasma
– Perifer pallisadering
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Adenoid Cystisk Carcinom
• Basaloide celler– Mørke, runde/ovale kjerner
– Lite cytoplasma
– Perifer pallisadering
• Lett/moderat atypi– Grovere enn ABC
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Adenoid Cystisk Carcinom
• Basaloide celler– Mørke, runde/ovale kjerner
– Lite cytoplasma
– Perifer pallisadering
• Lett/moderat atypi– Grovere enn ABC
• Mitoser
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Adenoid Cystisk Carcinom
• WHO Classification of Tumours of Female ReproductiveOrgans -2014:– ”Definition: A tumour that resembles adenoid cystic carcinoma of the
salivary gland”
• WHO Classification of Tumours, Head and Neck Tumours –2005:– ”Definition: ACC is a basaloid tumour consisting of epithelial and
myoepithelial cells in variable morphologic configurations, includingtubular, cribriform and solid patterns. It has a relentless clinical courseand usually a fatal outcome”
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Adenoid Cystisk Carcinom
• WHO Classification of Tumours of Female ReproductiveOrgans -2014:– ”Definition: A tumour that resembles adenoid cystic carcinoma of the
salivary gland”
• WHO Classification of Tumours, Head and Neck Tumours –2005:– ”Definition: ACC is a basaloid tumour consisting of epithelial and
myoepithelial cells in variable morphologic configurations, includingtubular, cribriform and solid patterns. It has a relentless clinical courseand usually a fatal outcome”
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Adenoid Cystisk Carcinom
• Cribriformt– Karakteristisk
– PAS+ materiale i lumen
• Tubulært
• Solid
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Adenoid Cystisk Carcinom
• Cribriformt– Karakteristisk
– PAS+ materiale i lumen
• Tubulært
• Solid
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Adenoid Cystisk Carcinom
• Cribriformt– Karakteristisk
– PAS+ materiale i lumen
• Tubulært
• Solid
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Adenoid Cystisk Carcinom
• Cribriformt– Karakteristisk
– PAS+ materiale i lumen
• Tubulært
• Solid
• Nekrose
• Stromal respons
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Adenoid Cystisk Carcinom
• WHO Classification of Tumours of Female ReproductiveOrgans -2014:– ”Definition: A tumour that resembles adenoid cystic carcinoma of the
salivary gland”
• WHO Classification of Tumours, Head and Neck Tumours –2005:– ”Definition: ACC is a basaloid tumour consisting of epithelial and
myoepithelial cells in variable morphologic configurations, includingtubular, cribriform and solid patterns. It has a relentless clinical courseand usually a fatal outcome”
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Adenoid Cystisk Carcinom
• WHO Classification of Tumours of Female ReproductiveOrgans -2014:– ”Definition: A tumour that resembles adenoid cystic carcinoma of the
salivary gland”
• WHO Classification of Tumours, Head and Neck Tumours –2005:– ”Definition: ACC is a basaloid tumour consisting of epithelial and
myoepithelial cells in variable morphologic configurations, includingtubular, cribriform and solid patterns. It has a relentless clinical courseand usually a fatal outcome”
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Adenoid Cystisk Carcinom
• «Påvist lungemetastaser etter ett år og cytostatikabehandlet. Død to år senere»
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Adenoid Cystisk Carcinom
• WHO Classification of Tumours of Female ReproductiveOrgans -2014:– ”Definition: A tumour that resembles adenoid cystic carcinoma of the
salivary gland”
• WHO Classification of Tumours, Head and Neck Tumours –2005:– ”Definition: ACC is a basaloid tumour consisting of epithelial and
myoepithelial cells in variable morphologic configurations, includingtubular, cribriform and solid patterns. It has a relentless clinical courseand usually a fatal outcome”
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Adenoid Cystisk Carcinom
• WHO Classification of Tumours of Female ReproductiveOrgans -2014:– ”Definition: A tumour that resembles adenoid cystic carcinoma of the
salivary gland”
• WHO Classification of Tumours, Head and Neck Tumours –2005:– ”Definition: ACC is a basaloid tumour consisting of epithelial and
myoepithelial cells in variable morphologic configurations, includingtubular, cribriform and solid patterns. It has a relentless clinical courseand usually a fatal outcome”
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Adenoid Cystisk Carcinom
Calponin
SMACK7
SMA
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Adenoid Cystisk Carcinom
SMA
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Adenoid Cystisk Carcinom• ”Myoepithelial cells are absent by light microscopy, but ultrastructural
examination in some cases have shown evidence of myoepithelial
differentiation” - Atlas of Gynecological Surgical Pathology: Expert consult (Clement, Young) – 2014
• ”However, unlike ACC of other sites, ACC contain few myoepithelial cellsdetected by electron microscopy or S100 and actin immunohistochemicalstains” - Blaustein`s Pathology of the Female Genital Tract (Kurman) – 2014
• ”ACC of the cervix lacks myoepithelial cells”
• ”Actin and S100 (…) are negative in most ACC of the cervix unlike ACC in other locations” - AFIP Atlas of Tumor Pathology, vol 13, series 4 (Kurman) – 2010
• ”Immunoperoxidase (…) may be used to characterize this tumor, includingmyoepithelial markers” - Biopsy Interpretation of the Uterine Cervix and Corpus (Malpica, Euscher)-2015
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Adenoid Cystisk Carcinom
• WHO Classification of Tumours of Female ReproductiveOrgans -2014:– ”Definition: A tumour that resembles adenoid cystic carcinoma of the
salivary gland”
• …videre:– ”There may be two tumours demonstrating this morphological
pattern, one being a true ACC and the other being an ACC-like basaloidsquamous cell carcinoma”
– ”Immunohistochemistry (…) can be used to distinguish these tumours, including myoepithelial markers”
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Adenoid Cystisk Carcinom
• Immunhistokjemi/spesialanalyser– CK, CK7
– p16
– PAS
– Myoepiteliale markører (?)
• SMA, S100, Calponin, p63
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Differensialdiagnoser
• Adenoid basalt carcinom– Eldre kvinner
– Basaloid
– Ofte kjerteldifferensiering
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Differensialdiagnoser
• Adenoid basalt carcinom– Eldre kvinner
– Basaloid
– Ofte kjerteldifferensiering
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Differensialdiagnoser
• Adenoid basalt carcinom– Eldre kvinner
– Basaloid
– Ofte kjerteldifferensiering
– Tilfeldig funn
– Ikke cribriform
– Ikke PAS+ hyalint materiale
– «Mangler» malignitetskriterier
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Differensialdiagnoser
• Andre carcinomer– Endometrioid
– «Usual» adenocarcinom
– Mesonefrisk carcinom• Eosinofilt luminalt materiale
– Småcellet carcinom• Nevroendokrine markører
– Basaloid plateepitelcarcinom• ACC-lik fenotype (WHO)
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Differensialdiagnoser
• Andre carcinomer– Endometrioid
– «Usual» adenocarcinom
– Mesonefrisk carcinom• Eosinofilt luminalt materiale
– Småcellet carcinom• Nevroendokrine markører
– Basaloid plateepitelcarcinom• ACC-lik fenotype (WHO)
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Differensialdiagnoser
• Andre carcinomer– Endometrioid
– «Usual» adenocarcinom
– Mesonefrisk carcinom• Eosinofilt luminalt materiale
– Småcellet carcinom• Nevroendokrine markører
– Basaloid plateepitelcarcinom• ACC-lik fenotype (WHO)
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Differensialdiagnoser
• Andre carcinomer– Endometrioid
– «Usual» adenocarcinom
– Mesonefrisk carcinom• Eosinofilt luminalt materiale
– Småcellet carcinom• Nevroendokrine markører
– Basaloid plateepitelcarcinom• ACC-lik fenotype (WHO)
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• Adenoid cystisk carcinom 18
• ACC eller «ACC-like basaloid squamous carcinoma» 1
• Lavt differensiert adenocarcinom 1
• Småcellet plateepitelcarcinom 1
• Basaloid carcinom 1
• Lavt differensiert carcinom 1
• Carcinom med blandet differensiering, cystisk/basaloid 1
Innsendte diagnoser
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Neste kasus…
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Kasus 8
41 år. Øvrig sykehistorie ukjent. Biopsi fra cervix.
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Desmin
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MyoD1
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Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
• RMS som komponent– Carcinosarcom/MMMT– Adenosarcom– Heterologt element
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Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
• RMS som komponent– Carcinosarcom/MMMT– Adenosarcom– Heterologt element
• Embryonalt RMS– Vulva og Vagina
• < 5år
– Cervix• Barn og unge kvinner• Rimelig god prognose• Ofte lokal eksisjon + CT/RT
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• RMS som komponent– Carcinosarcom/MMMT– Adenosarcom– Heterologt element
• Embryonalt RMS– Vulva og Vagina
• < 5år
– Cervix• Barn og unge kvinner• Rimelig god prognose• Ofte lokal eksisjon + CT/RT
• Pleomorft RMS– Postmenopausale kvinner
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
Dehner et al - 2011
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Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
Dehner et al - 2011
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Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
Dehner et al - 2011
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1/14 recidiv
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
Dehner et al - 2011
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• Sarcoma botryoides– Botrys (gr) – drueklase
– Cambium layer
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Sarcoma botryoides– Botrys (gr) – drueklase
– Cambium layer
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Sarcoma botryoides– Botrys (gr) – drueklase
– Cambium layer
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Sarcoma botryoides– Botrys (gr) – drueklase
– Cambium layer
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Sarcoma botryoides– Botrys (gr) – drueklase
– Cambium layer
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Sarcoma botryoides– Botrys (gr) – drueklase
– Cambium layer
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Sarcoma botryoides– Botrys (gr) – drueklase
– Cambium layer
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Sarcoma botryoides– Botrys (gr) – drueklase
– Cambium layer
• ”Non-botryoid” ERMS– Ikke cambium layer
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Udifferensierte celler– Små, ovale, hyperkromate kjerner– Lite cytoplasma– 2-12 mitoser/10HPF– Dette er IKKE lymfocytter!
• Myxoid / Ødem• Rhabdomyoblaster
– Større, avlange– Rikelig eosinofilt cytoplasma– +/- tverrstriping– Oftest (ikke alltid) til stede
• Brusk• Ofte bevarte kjertler !
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Udifferensierte celler– Små, ovale, hyperkromate kjerner– Lite cytoplasma– 2-12 mitoser/10HPF– Dette er IKKE lymfocytter!
• Myxoid / Ødem• Rhabdomyoblaster
– Større, avlange– Rikelig eosinofilt cytoplasma– +/- tverrstriping– Oftest (ikke alltid) til stede
• Brusk• Ofte bevarte kjertler !
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Udifferensierte celler– Små, ovale, hyperkromate kjerner– Lite cytoplasma– 2-12 mitoser/10HPF– Dette er IKKE lymfocytter!
• Myxoid / Ødem• Rhabdomyoblaster
– Større, avlange– Rikelig eosinofilt cytoplasma– +/- tverrstriping– Oftest (ikke alltid) til stede
• Brusk• Ofte bevarte kjertler !
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Udifferensierte celler– Små, ovale, hyperkromate kjerner– Lite cytoplasma– 2-12 mitoser/10HPF– Dette er IKKE lymfocytter!
• Myxoid / Ødem• Rhabdomyoblaster
– Større, avlange– Rikelig eosinofilt cytoplasma– +/- tverrstriping– Oftest (ikke alltid) til stede
• Brusk• Ofte bevarte kjertler !
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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• Udifferensierte celler– Små, ovale, hyperkromate kjerner– Lite cytoplasma– 2-12 mitoser/10HPF– Dette er IKKE lymfocytter!
• Myxoid / Ødem• Rhabdomyoblaster
– Større, avlange– Rikelig eosinofilt cytoplasma– +/- tverrstriping– Oftest (ikke alltid) til stede
• Brusk• Ofte bevarte kjertler !
Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
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Embryonalt Rhabdomyosarcom / Sarcoma Botryoides
• Desmin, MSA– Rhabdo OG leio
– Moden muskulatur
– Høyt og lavt differensierte
– Ikke udifferensierte
– Uspesifikk
• Myogenin, MyoD1– Myogenic nuclear regulatory proteins
– Tidlig i rhabdomyogenesen
– Lavt- og udifferensierte
– Rhabdomyosarcom
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• Inflammasjon
• Granulasjonsvev
• Granulasjonspolypp
• Cervixpolypp
• Etc…
Differensialdiagnoser
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• Inflammasjon
• Granulasjonsvev
• Granulasjonspolypp
• Cervixpolypp
• Etc…
• Ikke overse ERMS ”i farta”…
Differensialdiagnoser
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Differensialdiagnoser
• Adenosarcom– Epidemiologi
• Unge voksne kvinner
– Makroskopisk• Polypp
– Mikroskopisk• Benignt epitel + Malignt stroma
• Periglandulær hypercellularitet
• Varierende grad av atypi
• Heterologe elementer
– Brusk, fett, muskulatur, etc
• Sarcomatous overgrowth
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Differensialdiagnoser
• Adenosarcom– Epidemiologi
• Unge voksne kvinner
– Makroskopisk• Polypp
– Mikroskopisk• Benignt epitel + Malignt stroma
• Periglandulær hypercellularitet
• Varierende grad av atypi
• Heterologe elementer
– Brusk, fett, muskulatur, etc
• Sarcomatous overgrowth
– Men…• Fibrøs polypp, ikke «botryoid»
• «Leaf like», «phyllodes like»
• Ikke cambium layer
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• Embryonalt rhabdomyosarcom/sarcoma botryoides 9
• Rhabdomyosarcom 7
• Sarcom 3
• Småcellet carcinom? Adenosarcom? 1
• Infiltrerende småcellet carcinom 1
• Embryonalt carcinom 1
• Embryonalt. Usikker. 1
• Leiomyosarcom 1
Innsendte diagnoser
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Neste kasus…
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Kasus 10
Uterusamputert 39 år gammel, fjernet begge adnex 51 år gammel. Nå vaginalblødning. Snitt fra cervixstump.
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PAN-CK
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P16
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PAX5
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Mesonefrisk carcinom
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Mesonefrisk carcinom
• «Extremely rare»– Cirka 30 beskrevet
• ”Alle” aldre (34-72 år)
• 25% mortalitet
• Cervix >> corpus, vagina
• Klinisk tumor, blødning
• Ikke HPV-relatert
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Mesonefrisk carcinom
• «Extremely rare»– Cirka 30 beskrevet
• ”Alle” aldre (34-72 år)
• 25% mortalitet
• Cervix >> corpus, vagina
• Klinisk tumor, blødning
• Ikke HPV-relatert
• Mesonefric/Wolffianremnant…
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• Caspar Friedrich Wolff– 1735-94
– «Theoria Generationis», Univ i Halle, 1759
– Epigenesis
Preformasjonisme
Homunculus
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• Caspar Friedrich Wolff– 1735-94
– «Theoria Generationis», Univ i Halle, 1759
– Epigenesis
Preformasjonisme
Homunculus
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• Caspar Friedrich Wolff– 1735-94
– «Theoria Generationis», Univ i Halle, 1759
– Epigenesis
– «One of the founders of embryology»
– Wolffske gang (Ductus Mesonephricus)
Preformasjonisme
Homunculus
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• Caspar Friedrich Wolff– 1735-94
– «Theoria Generationis», Univ i Halle, 1759
– Epigenesis
– «One of the founders of embryology»
– Wolffske gang (Ductus Mesonephricus)
Fra Müllerske gang Fra Wolffske gang
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• Caspar Friedrich Wolff– 1735-94
– «Theoria Generationis», Univ i Halle, 1759
– Epigenesis
– «One of the founders of embryology»
– Wolffske gang (Ductus Mesonephricus)
• Mesonefriske-/Wolffske rester– Ovariehilus
– Ligamentum latum
– Lateralt/posterolateralt i cervix• 22% av voksne kvinner
– Lateralt/posterolateralt i vagina
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• Caspar Friedrich Wolff– 1735-94
– «Theoria Generationis», Univ i Halle, 1759
– Epigenesis
– «One of the founders of embryology»
– Wolffske gang (Ductus Mesonephricus)
• Mesonefriske-/Wolffske rester– Tilfeldig funn
– «Åpenbar» benign histologi
– Tubulære strukturer
• Ofte eosinofilt, PAS+ innhold
• Ofte omkring sentral gang
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Mesonefrisk carcinom
• Ofte mesonefrisk rest
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Mesonefrisk carcinom
• Ofte mesonefrisk rest
• Infiltrasjon/atypi/mitoser
• Lite/ingen vevsreaksjon
• Heterogenitet– 6 vekstmønstre
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Mesonefrisk carcinom
• Ofte mesonefrisk rest
• Infiltrasjon/atypi/mitoser
• Lite/ingen vevsreaksjon
• Heterogenitet– 6 vekstmønstre
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Mesonefrisk carcinom
• Tubulært– Eosinofilt hyalint materiale
• Duktalt– «Endometrioid-lignende»
• Retiformt
• ”Sex-cord like”
• Solid
• Sarcomatoid– Heterologe elementer?
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Mesonefrisk carcinom
• Tubulært– Eosinofilt hyalint materiale
• Duktalt– «Endometrioid-lignende»
• Retiformt
• ”Sex-cord like”
• Solid
• Sarcomatoid– Heterologe elementer?
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Mesonefrisk carcinom
• Tubulært– Eosinofilt hyalint materiale
• Duktalt– «Endometrioid-lignende»
• Retiformt
• ”Sex-cord like”
• Solid
• Sarcomatoid– Heterologe elementer?
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Mesonefrisk carcinom
• Tubulært– Eosinofilt hyalint materiale
• Duktalt– «Endometrioid-lignende»
• Retiformt
• ”Sex-cord like”
• Solid
• Sarcomatoid– Heterologe elementer?
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Differensialdiagnoser
• Mesonefrisk hyperplasi– Lobulær/diffus/ductal
– Subklinisk, «incidental finding»
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Differensialdiagnoser
• Mesonefrisk hyperplasi– Lobulær/diffus/ductal
– Subklinisk, «incidental finding»
– “Its distinction from mesonephric remnants is arbitrary and based on the appearance of the lobules, which are larger, more loosely organized and more irregularly shaped” (Robboy's Pathology of the Female Reproductive Tract, 2nd ed)
– “The distinction from mesonephric carcinoma is based on the disorderly invasion, back-to-back crowding, and cytologic atypia usually present in carcinoma” (Zaino, Modern pathology – 2000)
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Differensialdiagnoser
• Andre carcinomer
– «Usual» adenocarcinoma
– Endometrioid
– Adenoid cystisk carcinom• PAS+ materiale
– Serøst• Retiformt mønster
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Differensialdiagnoser
• Andre carcinomer
– «Usual» adenocarcinoma
– Endometrioid
– Adenoid cystisk carcinom• PAS+ materiale
– Serøst• Retiformt mønster
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Differensialdiagnoser
• Andre carcinomer
– «Usual» adenocarcinoma
– Endometrioid
– Adenoid cystisk carcinom• PAS+ materiale
– Serøst• Retiformt mønster
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Differensialdiagnoser
• Andre carcinomer
– «Usual» adenocarcinoma
– Endometrioid
– Adenoid cystisk carcinom• PAS+ materiale
– Serøst• Retiformt mønster
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Differensialdiagnoser
• Andre carcinomer
– «Usual» adenocarcinoma
– Endometrioid
– Adenoid cystisk carcinom• PAS+ materiale
– Serøst• Retiformt mønster
• Carcinosarcom• Heterogenitet
• Heterologe element
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Differensialdiagnoser
Residency Program - Case of the Month February 2010 Final Diagnosis - Presented by Mary Tomic, M.D. UC Davis Health system Sacramento Ca USA
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Differensialdiagnoser
Residency Program - Case of the Month February 2010 Final Diagnosis - Presented by Mary Tomic, M.D. UC Davis Health system Sacramento Ca USA
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Differensialdiagnoser
Residency Program - Case of the Month February 2010 Final Diagnosis - Presented by Mary Tomic, M.D. UC Davis Health system Sacramento Ca USA
P16PAX5
NegPos
PosNeg
Pos/NegNeg
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• Mesonefrisk carcinom 13
• Adenocarcinom 4
• Endometrioid carcinom 2
• Serøst carcinom 2
• Bifasisk tumor, carcinosarcom 1
• Nevroendokrint carcinom 1
• Lavt differensiert nevroendokrin tumor 1
Innsendte diagnoser
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Neste kasus…
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Kasus 13
68 år. Snitt fra cervixutskrap
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p16 neg ?
P53..?
Endometrium?
Adneks?
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Serøst carcinom
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Serøst carcinom
• Low grade serous carcinoma– Ovarium og peritoneum
• Serous borderline tumor (SBT)• ”invasive, distinctive patterns, low-
grade malignant cytological atypia”• P53wt, P16-• Ca 50 år
• High grade serous carcinoma– Tube, ovarium og peritoneum
• Serous intraep tubar carcinoma (STIC)• ”papillary, glandular and solid
patterns, high grade nuclear atypia”• Mutert P53, P16+• Ca 63 år
• Serous carcinoma– Endometrium
• Serous endometr intraep carcinoma• ”complex papillary or glandular,
marked nuclear pleomorphism”• Mutert P53, P16+• ”Postmenopausal women”
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Serøst carcinom
• Low grade serous carcinoma– Ovarium og peritoneum
• Serous borderline tumor (SBT)• ”invasive, distinctive patterns, low-
grade malignant cytological atypia”• P53wt, P16-• Ca 50 år
• High grade serous carcinoma– Tube, ovarium og peritoneum
• Serous intraep tubar carcinoma (STIC)• ”papillary, glandular and solid
patterns, high grade nuclear atypia”• Mutert P53, P16+• Ca 63 år
• Serous carcinoma– Endometrium
• Serous endometr intraep carcinoma• ”complex papillary or glandular,
marked nuclear pleomorphism”• Mutert P53, P16+• ”Postmenopausal women”
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Serøst carcinom
• Low grade serous carcinoma– Ovarium og peritoneum
• Serous borderline tumor (SBT)• ”invasive, distinctive patterns, low-
grade malignant cytological atypia”• P53wt, P16-• Ca 50 år
• High grade serous carcinoma– Tube, ovarium og peritoneum
• Serous intraep tubar carcinoma (STIC)• ”papillary, glandular and solid
patterns, high grade nuclear atypia”• Mutert P53, P16+• Ca 63 år
• Serous carcinoma– Endometrium
• Serous endometr intraep carcinoma• ”complex papillary or glandular,
marked nuclear pleomorphism”• Mutert P53, P16+• ”Postmenopausal women”
• Serous carcinoma– Cervix
• ?• ”rare, identical histological
appearance to endometrial or adnexal serous carcinoma”
• ?• ?
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Serøst carcinom
Ueda et al-2012
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Serøst carcinom
Ueda et al-2012
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Serøst carcinom
• 17 pasienter og recidiv
Zhou et al 1998
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Serøst carcinom
• 17 pasienter og recidiv
• Klinisk stadium
• Tumors størrelse
• Infiltrasjonsdybde
• Lymfeknutemetastase
Zhou et al 1998
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Serøst carcinom
• Bimodal aldersfordeling– <45 år (12stk), 3/10 recidiv
– >65 år (5stk), 4/5 recidiv
Zhou et al 1998
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Serøst carcinom
• Bimodal aldersfordeling– <45 år (12stk), 3/10 recidiv
– >65 år (5stk), 4/5 recidiv
Zhou et al 1998
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Serøst carcinom
• Bimodal aldersfordeling– <45 år (12stk), 3/10 recidiv
– >65 år (5stk), 4/5 recidiv
• p53 status– ”positive” 5/12 (??)
– ”most cells positive” 2/12 (?)• 4/5 recidiv
– ”negative” 7/12• 2/7 recidiv
Zhou et al 1998
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Serøst carcinom
• Bimodal aldersfordeling– <45 år (12stk), 3/10 recidiv
– >65 år (5stk), 4/5 recidiv
• p53 status– ”positive” 5/12 (??)
– ”most cells positive” 2/12 (?)• 4/5 recidiv
– ”negative” 7/12• 2/7 recidiv
Zhou et al 1998
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Serøst carcinom
• Bimodal aldersfordeling– <45 år (12stk), 3/10 recidiv
– >65 år (5stk), 4/5 recidiv
• p53 status– ”positive” 5/12 (??)
– ”most cells positive” 2/12 (?)• 4/5 recidiv
– ”negative” 7/12• 2/7 recidiv
• To ulike tumortyper?
Zhou et al 1998
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Serøst carcinom
Ueda et al-2012
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Serøst carcinom
Ueda et al-2012
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NOFECH-MOZES 2006
n=10
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NOFECH-MOZES 2006
n=10
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Serøst carcinom
• Primære serøse carcinom i cervix er sjeldne!
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Serøst carcinom
• Primære serøse carcinom i cervix er sjeldne!
• Finnes de?
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Serøst carcinom
• Primære serøse carcinom i cervix er sjeldne!
• Finnes de?
• Metastase fra HGSC i adneks?
• Direkte innvekst fra serøst carcinom i endometrium?
• Annen type primært adenocarcinom i cervixmed morfologi som HGSC?
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Serøst carcinom
• Primære serøse carcinom i cervix er sjeldne!
• Finnes de?
• Metastase fra HGSC i adneks?
• Direkte innvekst fra serøst carcinom i endometrium?
• Annen type primært adenocarcinom i cervixmed morfologi som HGSC?
• Primært serøst carcinom i cervix?
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Innsendte diagnoser
• Serøst carcinom 22
• Endometrioid carcinom 1
• Endocervicalt adenocarcinom, villoglandulær type 1
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Neste kasus…
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Case 19
63 år gammel kvinne med tumor i uterus. Utskrap.
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Primært myelosarcom
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Primært myelosarcom
• Ekstramedullær proliferasjon av umodne myeloide celler– Primært- uten leukemi– Sekundært - med leukemi
• Sjelden
• Alle aldre
• Utvikler ”alltid” AML
• Dårlig prognose
• Tidlig behandling KAN hjelpe
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Primært myelosarcom
• Ekstramedullær proliferasjon av umodne myeloide celler– Primært- uten leukemi– Sekundært - med leukemi
• Sjelden
• Alle aldre
• Utvikler ”alltid” AML
• Dårlig prognose
• Tidlig behandling KAN hjelpe
• Histologi– Diffus proliferasjon– Runde/rundovale kjerner– Lett-moderat atypi– Mitoser– Oftest monotont– Eventuelt differensiering
• CD68, MPO, CD117, CD99, CD34, TdT, CD56, CD30, etc…
• Differensialdiagnostikk– Husk at det finnes!
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Hematopoietisk stamcelle
Myeloid stamcelleLymfoid stamcelle
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Hematopoietisk stamcelle
Myeloid stamcelleLymfoid stamcelle
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Hematopoietisk stamcelle
Myeloid stamcelleLymfoid stamcelle
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Hematopoietisk stamcelle
Myeloid stamcelleLymfoid stamcelle
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Primært myelosarcom
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Primært myelosarcom
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Primært myelosarcom
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Primært myelosarcom
• Ekstramedullær proliferasjon av umodne myeloide celler– Primært- uten leukemi– Sekundert - med leukemi
• Sjelden
• Alle aldre
• Utvikler ”alltid” AML
• Dårlig prognose
• Tidlig behandling KAN hjelpe
• Histologi– Diffus proliferasjon– Runde/rundovale kjerner– Lett-moderat atypi– Mitoser– Oftest monotont– Eventuelt differensiering
• CD68, MPO, CD117, CD99, CD34, TdT, CD56, CD30, etc…
• Differensialdiagnostikk– Husk at det finnes!
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Primært myelosarcom
• Ekstramedullær proliferasjon av umodne myeloide celler– Primært- uten leukemi– Sekundert - med leukemi
• Sjelden
• Alle aldre
• Utvikler ”alltid” AML
• Dårlig prognose
• Tidlig behandling KAN hjelpe
• Histologi– Diffus proliferasjon– Runde/rundovale kjerner– Lett-moderat atypi– Mitoser– Oftest monotont– Eventuelt differensiering
• Differensialdiagnostikk– Inflammasjon– Lymfom– Carcinom (udiff, småcellet, …)– Sarcomer (ESS, UUS, …)– Etc etc
– CD68, MPO, CD117, CD99, CD34, TdT, CD56, CD30, etc…
– Husk at det finnes!
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Primært myelosarcom
• Ekstramedullær proliferasjon av umodne myeloide celler– Primært- uten leukemi– Sekundert - med leukemi
• Sjelden
• Alle aldre
• Utvikler ”alltid” AML
• Dårlig prognose
• Tidlig behandling KAN hjelpe
• Histologi– Diffus proliferasjon– Runde/rundovale kjerner– Lett-moderat atypi– Mitoser– Oftest monotont– Eventuelt differensiering
• Differensialdiagnostikk– Inflammasjon– Lymfom– Carcinom (udiff, småcellet, …)– Sarcomer (ESS, UUS, …)– Etc etc
– CD68, MPO, CD117, CD99, CD34, TdT, CD56, CD30, etc…
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Auodin et al - 2003
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Primært myelosarcom
• Ekstramedullær proliferasjon av umodne myeloide celler– Primært- uten leukemi– Sekundert - med leukemi
• Sjelden
• Alle aldre
• Utvikler ”alltid” AML
• Dårlig prognose
• Tidlig behandling KAN hjelpe
• Histologi– Diffus proliferasjon– Runde/rundovale kjerner– Lett-moderat atypi– Mitoser– Oftest monotont– Eventuelt differensiering
• Differensialdiagnostikk– Inflammasjon– Lymfom– Carcinom (udiff, småcellet, …)– Sarcomer (ESS, UUS, …)– Etc etc
– CD68, MPO, CD117, CD99, CD34, TdT, CD56, CD30, etc…
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Primært myelosarcom
• Ekstramedullær proliferasjon av umodne myeloide celler– Primært- uten leukemi– Sekundert - med leukemi
• Sjelden
• Alle aldre
• Utvikler ”alltid” AML
• Dårlig prognose
• Tidlig behandling KAN hjelpe
• Histologi– Diffus proliferasjon– Runde/rundovale kjerner– Lett-moderat atypi– Mitoser– Oftest monotont– Eventuelt differensiering
• Differensialdiagnostikk– Inflammasjon– Lymfom– Carcinom (udiff, småcellet, …)– Sarcomer (ESS, UUS, …)– Etc etc
– CD68, MPO, CD117, CD99, CD34, TdT, CD56, CD30, etc…
– HUSK AT DET FINNES !!
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Yamauchi & Yasuda (2002):74 pasienter, myelosarcom
Harris &Scully(1984):27 pasienter , lymfom eller myelosarcom i uterus/vagina
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Yamauchi & Yasuda (2002):74 pasienter, myelosarcom
Harris &Scully(1984):27 pasienter , lymfom eller myelosarcom i uterus/vagina
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Yamauchi & Yasuda (2002):74 pasienter, myelosarcom
Harris &Scully(1984):27 pasienter , lymfom eller myelosarcom i uterus/vagina
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Yamauchi & Yasuda (2002):74 pasienter, myelosarcom
Harris &Scully(1984):27 pasienter , lymfom eller myelosarcom i uterus/vagina
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Yamauchi & Yasuda (2002):74 pasienter, myelosarcom
Harris &Scully(1984):27 pasienter , lymfom eller myelosarcom i uterus/vagina
NB! HUSK AT DET FINNES…
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Innsendte diagnoser
• Myelosarcom 2
• Sarcom 4• Endometriestromasarcom 3• Neuroendokrin tumor 1
• Udifferensiert malign tumor 2• Spolformet malign tumor 3• Udifferensiert carcinom 2
• Udifferensiert carcinom? Småcellet carcinom? Epitelioid leiomyosarcom? Endometriestromasarcom? Sarcom? Lymfom? Melanom? 5
• Leiomyom 1• Carcinosarcom (myelosarcom) 1
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Neste kasus…
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Kasus 40
67 år. Utskrap fra corpus uteri.
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Espinosa et al, 2015
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MammaglobinGCDFP-15
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Metastase til uterus
fra lobulært carcinom i mamma
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Metastase til uterus
• Sjelden– Abrams 1950
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Metastase til uterus
• Sjelden– Abrams 1950
• 5,9% uterus
• 0,3% cervix
– Sjeldnere i dag?
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Metastase til uterus
• Sjelden– Abrams 1950
• 5,9% uterus
• 0,3% cervix
– Sjeldnere i dag?
• Ofte kjent grunnsykdom– ”enkel” diagnostikk
• Primær manifestasjon– Ofte vanskelig
• Klinikk ”som gyn primærtx”
• Histologi ”som gyn primærtx”
• Sjelden; tenker ikke på det…
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• Genitalt origo, adneks
Metastase til uterusMenczer et al 2010:Cancer ovarii, stg II-IV, hysterektomert, n=554
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• Genitalt origo, adneks– Uterusaffeksjon 52%
Metastase til uterusMenczer et al 2010:Cancer ovarii, stg II-IV, hysterektomert, n=554
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• Genitalt origo, adneks– Uterusaffeksjon 52%
– 40% økt risiko ved HGSC
Metastase til uterusMenczer et al 2010:Cancer ovarii, stg II-IV, hysterektomert, n=554
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• Genitalt origo, adneks– Uterusaffeksjon 52%
– 40% økt risiko ved HGSC
– Mikroskopisk 38%
– Makroskopisk 14%
Metastase til uterusMenczer et al 2010:Cancer ovarii, stg II-IV, hysterektomert, n=554
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• Genitalt origo, adneks– Uterusaffeksjon 52%
– 40% økt risiko ved HGSC
– Mikroskopisk 38%
– Makroskopisk 14%
– «Ikke endometrium» 37% («70%»)
Metastase til uterusMenczer et al 2010:Cancer ovarii, stg II-IV, hysterektomert, n=554
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• Genitalt origo, adneks– Uterusaffeksjon 52%
– 40% økt risiko ved HGSC
– Mikroskopisk 38%
– Makroskopisk 14%
– «Ikke endometrium» 37% («70%»)
– Kun endometrium 3,4% («6,5%»)
– Endometrium mm 8,6% («16%»)
Metastase til uterusMenczer et al 2010:Cancer ovarii, stg II-IV, hysterektomert, n=554
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• Genitalt origo, adneks– Uterusaffeksjon 52%
– 40% økt risiko ved HGSC
– Mikroskopisk 38%
– Makroskopisk 14%
– «Ikke endometrium» 37% («70%»)
– Kun endometrium 3,4% («6,5%»)
– Endometrium mm 8,6% («16%»)
– Altså; carcinom i myometrium og serosa men ikke endometrium
…suspekt!
Metastase til uterusMenczer et al 2010:Cancer ovarii, stg II-IV, hysterektomert, n=554
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• Genitalt origo, adneks– Uterusaffeksjon 52%
– 40% økt risiko ved HGSC
– Mikroskopisk 38%
– Makroskopisk 14%
– «Ikke endometrium» 37% («70%»)
– Kun endometrium 3,4% («6,5%»)
– Endometrium mm 8,6% («16%»)
– Altså; carcinom i myometrium og serosa men ikke endometrium
…suspekt!
• Genitalt origo, annet– Metastase
– Direkte innvekst
Metastase til uterusMenczer et al 2010:Cancer ovarii, stg II-IV, hysterektomert, n=554
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• Extragenitalt origo
Metastase til uterus
Kumar et al 1982 : 63 kvinner med extragenital cancer og metastase til uterus
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• Extragenitalt origo– Mamma 43%
– Colon 18%
– Ventrikkel 11%
– Pancreas 11%
Metastase til uterus
Kumar et al 1982 : 63 kvinner med extragenital cancer og metastase til uterus
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• Extragenitalt origo– Mamma 43%
– Colon 18%
– Ventrikkel 11%
– Pancreas 11%
– Kun myometrium 64%
– Endo- og myometrium 33%
– Kun endometrium 4%
Metastase til uterus
Kumar et al 1982 : 63 kvinner med extragenital cancer og metastase til uterus
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• Extragenitalt origo– Mamma 43%
– Colon 18%
– Ventrikkel 11%
– Pancreas 11%
– Kun myometrium 64%
– Endo- og myometrium 33%
– Kun endometrium 4%
– Altså; carcinom i myometrium men ikke endometrium…suspekt!
Metastase til uterus
Kumar et al 1982 : 63 kvinner med extragenital cancer og metastase til uterus
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Metastase til uterus
• Carcinom kun i serosa og/eller myometrium?
• Dersom endometrium/-cervix– Bevarte benigne kjertler?
– In-situ lesjoner?
• Spesifikk ”uterus-fremmed” morfologì?– Single files
– Dirty necrosis
– Signetringceller
– Andre
• Sykehistorie !!!
• Immunhistokjemi…
• Immunhistokjemi…
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Metastase til uterus
• Carcinom kun i serosa og/eller myometrium?
• Dersom endometrium/-cervix– Bevarte benigne kjertler?
– In-situ lesjoner?
• Spesifikk ”uterus-fremmed” morfologì?– Single files
– Dirty necrosis
– Signetringceller
– Andre
• Sykehistorie !!!
• Immunhistokjemi…
• Immunhistokjemi…
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Metastase til uterus
• Carcinom kun i serosa og/eller myometrium?
• Dersom endometrium/-cervix– Bevarte benigne kjertler?
– In-situ lesjoner?
• Spesifikk ”uterus-fremmed” morfologì?– Single files
– Dirty necrosis
– Signetringceller
– Andre
• Sykehistorie !!!
• Immunhistokjemi…
• Immunhistokjemi…
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Metastase til uterus
• Carcinom kun i serosa og/eller myometrium?
• Dersom endometrium/-cervix– Bevarte benigne kjertler?
– In-situ lesjoner?
• Spesifikk ”uterus-fremmed” morfologì?– Single files
– Dirty necrosis
– Signetringceller
– Andre
• Sykehistorie !!!
• Immunhistokjemi…
• Immunhistokjemi…
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Metastase til uterus
• Carcinom kun i serosa og/eller myometrium?
• Dersom endometrium/-cervix– Bevarte benigne kjertler?
– In-situ lesjoner?
• Spesifikk ”uterus-fremmed” morfologì?– Single files
– Dirty necrosis
– Signetringceller
– Andre
• Sykehistorie !!!
• Immunhistokjemi…• Immunhistokjemi…
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Innsendte diagnoser
• Metastase fra lobulært carcinom 9
• Metastase fra malignt melanom 3• Endometriepolypp med metastase 2• Signetringcellecarcinom. Metastase? 2• Metastase fra adenocarcinom 1• Metastase? 1
• Endometriepolypp med infiltrasjon av carcinom 1• Infiltrerende carcinom 1• Klarcellet carcinom 1• Atypisk leiomyom? Metastase fra ventrikkelcarcinom? 1• Malign tumor 1• Pecom 1
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Neste kasus…
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Takk for meg…