DIAGNOSIS AND qOMMENTS: This is a moderately differentiated early gastric carcinomapT1, N1, V1, RO. A diagnosis without attempt at staging is not acceptable in this case.

•

1) F, 35, Large GIST, Pre-Op Imatinib with some response on CT.CONSULTANTSPleomorphic (rhabdomyo) sarcomaMalignant (epithelioid) GISTCD34+ve, CD117 negative GIST vs Leiomyosarcoma or MPNST ? Imatinib resistanceBenign epithelioid GISTMixed GANT/GISTRESIDENTS(Malignant epithelioid) GIST (with some evidence of response)GIST vs (pleomorphic) (Rhabdomyo) sarcoma(Epithelioid) leiomyosarcomaAnaplastic large cell lymphoma

42221

8521

DIAGNOSIS AND COMMENTS: This is a paediatric type GIST showing resistance toimatinib. It belongs to the class of wild-type GIST in which the recently decribed molecularabnormality is a deficiency in the succinate dehydrogenase enzyme complex. The earlierdescribed GIST classes show abnormality of either c-kit or PDGFRA.

2) F, 76, Pre-pyloric gastric lesionCONSULTANTSHigh grade (severe) dysplasia 4(Early) gastric adenocarcinoma (?background Peutz-Jeghers polyp) 4Gastric adenoma 1TVA with severe dysplasia 1Hyperplastic polyp 1RESIDENTSAdenocarcinoma - (stage: T1NOMO, pT3, Nx, Mx, intramucosal, LN mets - 1 person each) 12Intestinal metaplasia 1Severe dysplasia (+H.Pylori associated gastritis) 1TVA with low-grade dysplasia 1Cystic fundic polyp 1

3) F, 58, Duodenal cap polyp.CONSULTANTSLeiomyosarcoma(well differentiated) Neuroendocrine tumour (vascular invasion)Small cell neuroendocrine carcinomaGIT carcinoidGangliocytic paragangliomaGlomus tumour/glomangiomaGISTRESIDENTSNeuroendocrine tumour/carinoma (G2T2NOMO)(high grade) 9Carcinoid tumour 4GIST 2Fibrosarcoma 1DIAGNOSIS AND COMMENTS: This is an incompletely excised grade 1 neuroendocrinecarcinoma. The term carcinoid is no longer in use for these tumours.

32211

4) M, 73, Small bowel tumourCONSUL TANTS_GIT carcinoid tumour(well differentiated) Neuroendocrine tumourRESIDENTSCarcinoid tumour (with vascular, nodal, perineural invasion)(well differentiated) Neuroendocrine tumour/carcinoma (G2,T3,N1 ,MO)DIAGNOSIS AND COMMENTS: Grade 1 neuroendocrine carcinoma pT4, N1, V1

83

106

5) M, 61, History of anaplastic T-cell lung and mediastinal lymphoma. Treatedwith CHOP. Previous small bowel resection and formation of jejunostomy.Restoration of bowel continuitywith resection of bowel proximal to jejunostomyCONSULTANTSChronic inflammation (Enteritis)Diverticulosis/diverticular diseaseEnteropathy associated T-cell lymphomaProtozoan infection (?isosporiasis)Diversion colitisNo answerIntestinal metaplasiaNon-Hodgkin's lymphomaRESIDENTSNo answerAdenocarcinomaHyperplastic polyp/Mucosal hyperplaslaEnteropathy associated T-cell lymphomaEffects of chemotherapyStasis syndrome? GIST with adenocarcinoma T1Coeliac diseaseTubular adenomaNon-Hodgkin's lymphomaDIAGNOSIS AND GOMMENTS: Enteropathy associated T-cell lymphoma (arising in abackground of coeliac disease). The previously diagnosed chest tumour was actually asecondary from this.

321111

5221111111

6) M, 60, ? Sigmoid carcinomaCONSUL TANTSTubulovillous carcinoma, papillary adenocarcinoma, mucinous adenocarinomaVillous adenoma with pseudo-invasionlTVA with epithelial misplacementPeutz Jegher's polyp/harmatomaTubular adenomaAdenocarcinoma arising in villous adenomaRESIDENTSAdenocarcinoma arising in villous adenomaAdenocarcinomaVillous adenoma (with low grade dysplasia)Peutz Jegher's polyp/harmatomaVilloglandular polyp with pseudoinvasionNon-Hodgkin's lymphomaDIAGNOSIS AND COMMENTS: Tubulovillous adenoma with high-grade dysplasia andepithelial misplacement (no invasive adenocarcinoma)

53111

43332

I

7) M, 78, Sigmoid tumourCONSULTANTSMucinous adenocarcinomaMucinous adenocarcinoma pT2, NX,MxAdenocarinioma with serosal involvementAdenocarinoma in subserosaRESIDENTSAdenocarcinoma T2NOMO 4Mucinous adenocarcinoma (with vascular embolus in serosa) 4Adenocarcinoma stage 3/pT3 4Adenocarinoma Duke B 1Adenocarcinoma Astler Coller at least stage B1 1Adenocarcinoma with serosal spread 1Adenocarcinoma with vascular invasion Duke stage C 1DIAGNOSIS AND COMMENTS: Moderately differentiated adenocarcinoma pT2, NO,V1,RO. Dukes A. A diagnosis without staging is not acceptable in this case.

8) F, 63, Low rectal tumor, pre-op radiotherapyCONSUL TANTSAdenocarcinoma (with radiation changes)Adenocarcinoma with tumour in subserosaAdenocarinoma with trophoblastic differentiationMetastatic adenocarcinoma (or melanoma - brown pigment seen)Adenocarcinoma, background ulcerative colitis and flat adenoma + satellite tumour noduleRESIDENTS(Residual) adenocarcinoma (with radiation changes)Adenocarcinoma pT3,Nx, MxMetastatic adenocarcinomaAdenocarcinoma with serosal and Iymphovascular spreadAdenocarcinoma pT2,Nx,Mx

DIAGNOSIS AND COMMENTS: Residual adenocarcinoma (partial response toneoadjuvant therapy), ypT3, N1, V1, RO. A diagnosis without staging is not acceptable .

7211

71111

75211

r

.9) M, 78, Splenic flexure tumour.CONSUL TANTSMetastatic serosal/omental adenocarcinoma (primary tumour not seen, ? prostatic)AdenocarinomaAdenocarcinoma NOS, extends to serosaRESIDENTS? Metastatic adenocarcinomaAdenocarcinoma T3,NO,MOAdenocarcinomaAdenocarcinoma T4aAdenocarcinoma T2,Nx,MxAdenocarcinoma Dukes' stage BAdenocarcinoma with serosal spreadAdenocarcinoma with vascular invasion Dukes' CDIAGNOSIS AND COMMENTS: Adenocarcinoma pT4, N2, V1, RO. Dukes' C1. Adiagnosis without staging is not acceptable.

641

43321111

5531111

10) M, 52, Hepatic flexure tumourCONSULTANTSMucinous adenocarcinoma, Colloid carcinoma 5Papillary carcinoma floating in mucin 3Mucinous adenocarcinoma with transmural involvementMucinous cystadenoma with low grade dysplasiaMucinous adenocarcinoma pT3, Nx, MxRESIDENTS(Mucinous) adenocarcinoma 6Mucinous adenocarcinoma pT3, Nx, Mx 5Mucinous adenocarcinoma stage 1 2No answerMucinous adenocarcinoma Dukes' stage BMucinous adenocarcinoma with serosal/peritoneal metastasisDIAGNOSIS AND COMMENTS: (serrated) mucinous adenocarcinoma pT4, N2, VO, RO,Dukes' C1. A diagnosis without staging is not acceptable.

11) F, 26, Haemorrhoids? polypoid componentCONSULTANTSInverted papillooma (with haemorrhoids)Squamous carcinoma in-situ/AIN (with haemorrhoid)Haemorrhoids and condyloma acuminatumHaemorrhoids and squamous metaplasia of mucous glandsKeratoacanthomaVerrucae vulgaris _Verrucous carcinoma with haemorrhoidsRESIDENTS(Haemorrhoids and) condyloma acuminatum(Thrombosed) haemorrhoidsHaemorrhoids with squamous (inverted) papillomaHaemorrhoids with basal cell carcinomaHaemorrhoids with verruca accuminataPseudoepitheliomatous hyperplasiaVerrucous carcinomaDIAGNOSIS AND COMMENTS: Haemorrhoid with viral wart and AIN3

3211111

931111

12) M, 81, Multiple skin tags.CONSUL TANTSSquamous cell carcinomaInverted papillomaTrichilemmoma (Cowden's syndrome)Basosquamous carcinomaHypertrophied anal papillaeKeratoacanthomaRESIDENTSSquamous cell carcinoma (in a fibroepithelial polyp)Fibroepithelial polyp (achrochordon)Extramammary Paget's diseaseNeurofibroma with basosquamous carcinomaMetastatic squamous cell carcinomaNo answerDIAGNOSIS AND COMMENTS: Well differentiated SCC at the base of a fibroepithelialpolyp.

521111

13) Gastric biopsy from 55 year old femaleCONSULTANTSH.pylori assoc chronic gastritis (with atrophy) and intestinal metaplasia 4Mild active chronic gastritis (with atrophy) 2Inflammatory myofibroblastic tumour (and benign gastric ulcer) 2Chronic active gastritis with severe dysplasia 1H. Pylori associated chronic gastritis 1Moderate chronic inflamm. No activity, HLO, atrophy, metaplasia or dysplasia 1RESIDENTSH.Pylori assoc chronic active gastritis 3Chronic gastritis (non-specific) 3No answer 3Reactive gastritisNormalMild active chronic inflamm. No HLO, atrophy, metaplasia or dysplasiaChronic gastritis with dysplastic changesMild active chronic gastritis with moderate atrophy but no metaplasiaChronic atrophic gastritis 1Collagenous gastritis 1DIAGNOSIS AND COMMENTS: Moderate inactive chronic gastritis with mild atrophy. Nointestinal metaplasia or epithelial dyplasia seen. H.pylori not identified (though probablyrelated).

14) Liver biopsy from 2 month old male

IICONSUL TANTSGiant cell' hepatitisLiver biopsy from 2 month old maleNeonatal hepatitis with liver·cirrhosis (likely due to biliary tree obstruction)Biliary cirrhosisNeonatal hepatitis with residual extramedullary haematopoeisisAcute hepatitis with giant cell transformation? Alpha-1 anti-trypsin defeciencyRESIDENTSNo answerHepatoblastomaCholestasis (? Alpha-1 anti-trypsin defeciency)Wilson's diseaseLanghan's cell histiocytosisGiant cell hepatitis (?storage disease)SteatohepatitisBiliary atresiaHepatocellular carcinomaExtramedullary haematopoesisHaemophagocytic syndrome/storage diseaseCapillary haemangiomaNeonatal hepatitisDIAGNOSIS AND COMMENTS: Neonatal (giant cell) hepatitis with evidence of residualextramedullary haematopoesis. No significant/established fibrosis and no clear cutunderlying aetiology.

3221111 11'

22211111 ,11111

15) Caecal pole tumour in a 45 year old male

CONSULTANTSSignet ring cell carcinoma (metastatic)LiposarcomaMucinous carcinoma/AdenocarcinomaCollision tumour (carcinoid and adenocarcinoma)Neuroendocrine carcinoma

RESIDENTSAdenocarcinomaMetastatic squamous cell carcinomaNeuroendocrine tumour/carcinomaCarcinoidSignet ring adenocarcinomaMixed adenoneuroendocrine carcinoma T3NOMOSignet ring adenocarcinoma T4aSignet ring cell carcinoma Dukes BMetastatic mucinous carcinomaPoorly differentiated carcinoma

DIAGNOSIS AND COMMENTS: Poorly differentiated/signet ring cell adenocarinoma pT4a.A diagnosis without staging is not acceptable.

16) Sigmoid colon polyp in 48 year old male.

CONSUL TANTSAdenomatous polyp with severe (high grade) dysplasia/high grade adenomatous polypTubular adenomaAdenomatous polypTubular adenoma ~ith low-grade dysplasiaTubulovillous adenoma

RESIDENTSTubular adenoma (to rule out adenomatous polyp)AdenocarcinomaAdenomatous polypTubular adenoma with low grade dysplasiaSerrated adenomaPeutz-Jegher's polypAdenomatous polyp high gradeDysplastic polypSevere dysplasia

DIAGNOSIS AND COMMENTS: Tubular adenoma with low grade epithlial dysplasia only.Size not estimated because sample is just a fragement. A diagnosis without grade ofdysplasia is not acceptable.

43211

3222211111

53111

42222111

·CONSULTANTSChronic (viral) hepatitis 4Chronic (viral) hepatitis Metavir score 3, Ishak score 5 stage 1 2Chronic (viral) hepatitis n-e-ed:.seeciaIstains for staging 1Chronic (viral) hepatitis, bridging fibrosis, portal and focal mild parenchymal inflammation 1Chronic active hepatitis with piece meal necrosis and steatosis 1Chronic hepatitis (HAI:A-2,B-1,C-2,D-2=7/18~ fibrosis 2/6) ?aetiology 1Chronic (viral) hepatitis with minimal fibrosi~ an~ r_iecrosis . 1RESIDENTS

17) Distal partial gastrectomy in 47 year old male. History of upper abdominal painfor 3 months. 6 cm tumour found in antrum. Distance to nearest margin 1 em,

CONSULTANTSAdenocarcinoma (intestinal, papillary) with Iymphnode metsAdenocarcinoma (with LN mets) pT2N1 MxRESIDENTSAdenocarcinoma (with lymph node mets)No answerMucinous adenocarcinoma stage 2Adenocarcinoma T2, N1, Mx - (stage 3)Adenocarcinoma (papillary) T3N 1MOHypertrophic polypGastric adenocarcinoma with lymph node castleman's disease + papillary structures notmets

DIAGNOSIS AND COMMENTS: Intestinal type adenocarcinoma pT2, N1, V1. A diagnosiswithout staging is not acceptable in this case.

18) Liver biopsy in 63 year old female.

Chronic (viral) hepatitisNo answerChronic (viral) hepatitis Scheuer grade2 stage2InadequateViral hepatitis with fibrosisAscending cholangitisSteatohepatitis in a background of liver cirrhosissteatosis with portal triaditisChronic hepatitis with haemochromatosisPrimary sclerosing cholangitis

DIAGNOSIS AND COMMENTS: chronic (viral) hepatitis. Necro-inflammatory grade 2,fibrosis stage 1. In truth, special stains are required for adequate grading and staging, butan attempt should be made even on HIE. Most important is the need to adopt a uniformsystem for the whole country.

92

722211

52211

1

20) Gastric biopsy in 45 year old femaleCONSUL TANTSMALT lymphoma/MAL TomaSevere chronic gastritisNon-Hodgkin's lymphoma? MALToma: do immuno (C023, C05, C01O),RESIDENTSMALTomaNon-Hodgkin's lymphoma(diffuse) Adenocarcinoma in a background of chronic atrophic gastritisCarcinoid tumourAtrophic autoimmune gastritisFungal (candidal) injectionNo answer

5321

19) Oesophageal biopsy in 69 year old maleCONSUL TANTSFungal/candidal oesophagitis (needs PAS, GMS)Chronic oesophagitisEpithelial hyperplasia with koilocytic atypia/HPV oesophagitisHerpes oesophagitisGEROAdenocarcinomaRESIDENTSGERO, (no dysplasia)No answerBarret's OesophagusSquamous papillomaWell differentiated SCCPoorly differentiated adenocarcinomaMetastatic adenocarcinomaFungal/candidaloesophagitis

33211

54211111

DIAGNOSIS AND COMMENTS: GERO, no evidence of metaplasia (Barret's) or dysplasia

5422111

DIAGNOSIS AND COMMENTS: MALT lymphoma - a diagnosis that would requireimmunohistochemistry

21) 63 year old male with history of prostatic carcinoma. ? Metastasis toankle (biopsied). IMMUNOHISTOCHEMISTRY: The cells do not expressbroad spectrum cytokeratins (AE1/3), S100 or desmin but are positive withCD34 and HHV-8.CONSULTANTSKaposi sarcomaRESIDENTSKaposi sarcomaNo answer? Sarcoma

11

1411

DIAGNOSIS AND COMMENTS: Kaposi's sarcoma (morphology quite unusual).

(\

22) 63 year old female with granulomatous skin nodule over chest tube site.IMMUNOHISTOCHEMISTRY: Lesional cells express CK7, CK20, TTF-1and weakly oestrogen receptors. They are negative with progesteronereceptors, calretinin and WT-1.

CONSULTANTSAdenocarcinoma mets from lungAdenocarcinoma mets from colonAdenocarcinoma mets from pancreas or bile ductAdenocarcinoma mets from breastRESIDENTSAdenocarcinoma mets from lungNo answerAdenosquamous carcinoma mets from lung? Lobular carcinomaInvasive ductal carcinomaAdenocarcinoma mets from pancreasPyogenic granuloma

DIAGNOSIS AND COMMENTS: Adenocarcinoma of primary lung origin

6311

8221111

23) Male 54 years, lesion on posterior aspect of right arm. Severe pain onthe right arm for 2 years. ? Neuroma. IMMUNOHISTOCHEMISTRY:Tumour cells are negative with AE1/3, S100 and CD34 but show a stronguniform expression of SMA.

CONSULTANTSGlomus tumour/GlomangiomaRhabdomyosarcomaNodular fascitisRESIDENTSGlomus tumour/GlomangiomaNo answerMetastatic carcinoidEpithelioid leiomyosarcoma

DIAGNOSIS AND COMMENTS: Glomus tumour/glomangioma

731

9421

,

24) Chest wall mass from an 87 year old female. ? Metastatic tumour.IMMUNOHISTOCHEMISTRY: para nuclear dot-like positivity with broad-spectrum cytokeratins (AEU3), but no expression ofCK7 and CK20. Stronguniform expression ofCDS6, synaptophysin and weak expression of Bcl-2. Noexpression ofTTF-l, NFP, CDS, CD20 or DesminCONSULTANTSMetastatic (large or small cell) neuroendocrine carcinoma ? From lungSynovial sarcomaPNETRESIDENTSNo answerMetastatic (large or small cell) neuroendocrine carcinoma? From lungNeuroendocrine tumour

DIAGNOSIS AND COMMENTS: cutaneous neuroendocrine (Merkel cell) carcinoma

911

664

PARTICIPANTS

CONSULTANTS code namesFS123abc123Senior MOarlabokiEleGyration 13Junior MSunday Mangel 74EKORESIDENTS code namesBlast 101path20135sigmaOLUCHUKWU 82ngdasel82Azeke AkhatorUBEovayozaUmar MohammedHISTOBEDROCKMessiahOLUCHUKWUATURU 44Ajokekpeb 22Zinc

II

,

II