Unknown primary tumors : common misdiagnosis Oscar Nappi UOSC di Anatomia patologica AORN A....
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Transcript of Unknown primary tumors : common misdiagnosis Oscar Nappi UOSC di Anatomia patologica AORN A....
Unknown primary tumors :common misdiagnosis
Oscar NappiUOSC di Anatomia patologica
AORN A. Cardarelli - Napoli
Shapira DV, Jarrett ARThe need to consider survival, otcome and expense when
evalueting and treating patients with unknown primary carcinomaArch Intern Med 155 : 2050-2054, 1995
• 56 pts with CUP • The average cost to each patient for clinical
procedures was 17.973 dollars• Only in 4 cases the primary tumor was found• None of the neoplasms was deemed curable
and less than 20% of the patients survived more than 12 months after initiation of therapy
Pathologist’s role in management of unknown primary tumors
• Conventional cyto- histologic studies correlated to clinical setting
• IMMUNOHISTOCHEMICAL STUDIES
• Molecular biomarkers microRNAs GEP ( gene expression profiling )
M 64 ysCerebral mass
Questo è un linfoma maligno
anaplastico
Guarda il citoplasma…per me è un sarcoma
epiteliode !
Ma..! Le cellule sono incise e
macronucleolate. E se fosse un carcinoma ?
Neoplasia maligna, n.a.s., quadro compatibile con carcinoma scarsamente differenziato (origine ignota) metastatico
Diagnosi finale
S100 HMB45
Metastatic melanoma
Polygonal large cell tumor Immunoistochemical algorytm
Unknown primary tumorsCommon misdiagnosis
Unknown primary tumorsDangerous misdiagnosis
• Not diagnosing a malignant lymphoma• Not diagnosing an endocrine tumor • Not diagnosing other neoplasias with a favorable ( or relatively favorable ) therapeutical approach
Some neoplasias with a favorable
( or relatively favorable ) therapeutical approach
• Breast• Prostate• Extragonadal germ cell • “Peritoneal carcinoma”• Others
CD45
Large cell B lymphoma
Cytokeratin expression in hematological neoplasms:a tissue microarray study on 866 lymphoma and
leukemia cases
Adams H, Schmid P, et alPathol Res Pract 204 : 569- 573, 2008
0,4% HD0,6% B-LCLO,7 % Peripheral T cell Lymphoma0,7% Myeloma4% Small cell ymphoma26% Mantle cell lymphoma
Case 1
Pazient : F ys 46Clinics and imagingfavour a diagnosis ofmeningioma
CK 20 LCA
CK
Mammaglobin
CK7
HER2
ER
IHC in distinguish SCC and AC in poorly differentiated lung tumours
TypeTTF-1
p6334betaH11
Napsin A
SCC _ _ _ +++ _ _ _
ADENO +++ _ _ _ +++
Clinical Case
• M 47 ys• Multiple bone metastasis ( 2 vertebral bodies, femur ) and multiple nodules in both lungs• FNA CAT-guided of a peripheral lung nodule
TTF1
Napsin A
Clinical case
• Metastatic lung adenocarcinoma
Also positive in mesothelioma and in so called Primary peritoneal carcinoma
Clinical case
• M 38 ys• Axillary lymphadenopathy, retroperitoneal mass• No other apparent neoplastic lesions found• A lymphadenectomy is performed
Clinical case• Immunohistochemical study pan CK positive CK 7 positive CK 20 negative PSA negative TTF-1 negative napsin A negative villin negative
Adenocarcinoma NOS
Clinical case
• CD 30 +++• PLAP ++-• OCT 4 +++
Germ cell tumor Embryonal carcinoma
CD30
Clinical Case
• Male ys 63
• Multiple hepatic nodules
• At a first preliminary screening by CAT no other neoplastic lesions
found
?
Case
Preliminary immunohistochemical study :• CD45 NEGATIVO• HMB45 NEGATIVO• S-100 NEGATIVO• VIMENTINA NEGATIVA• Pan CK POSITIVA
TTF-1
CK7
Poorly differentiated adenocarcinoma of the lung ?
NE Markers !!
• Chromogranin A• Synaptophisin• CD56• CD57
• Negative• Weakly and Focal +
Ki67 > 15%
High grade NE large cell carcinoma of the lung CD56
Dangerous misdiagnosis
Metastatic mimicking primary tumors• Lung• Liver• Ovary• Thyroid• Breast• Any organ
METASTASI ENDOBRONCHIALI: QUADRI RADIOLOGICI INDISTINGUIBILI DALLA NEOPLASIA POLMONARE PRIMITIVA
METASTASI A LOCALIZZAZIONE ENDOBRONCHIALE DA TUMORI EXTRA-POLMONARI: STUDIO EPIDEMIOLOGICO E CLINICO-PATOLOGICO
Ca sigma Ca stomaco
Grazie