Personal moment: so immensely proud of our son, Yonatan A. Fine, as he graduates
@YUNews
honored as Yeshiva College Valedictorian 🎓 & heads to
@YaleLawSch
#graduation2024
Evolution in Grading of
#prostatecancer
(PCa)
PCa Variants not previously accounted for in original Gleason scheme were incorporated, including 'B9-appearing' ones [depicted below]:
✨Foamy
✨Atrophic
✨Pseudohyperplastic
✨Microcystic
#ProstateCancerawarenessmonth
#gupath
1/n
Benign spermatic cord finding
#1
: Leydig cells involving nerves - a NOT uncommon finding that should NOT be misconstrued as tumor
#gupath
#testis
#mimics
Especially with a fresh cohort of
#pathology
trainees out there, I thought it may be time for a
#gupath
refresher on
#Prostate
Anatomy
✴️ Did you know that its modern history can be attributed to Dr. John E. McNeal from
@StanfordMed
?1/n
Special shout-out to my
#gupath
colleague and mentor, Dr. Victor Reuter
@MSKPathology
being honored with the Board’s Distinguished Pathologist Award
#USCAP2022
for his long-standing contributions to
@TheUSCAP
Potential pitfall in
#gupath
- von Brunn nests in upper tract (ureter; renal pelvis) are typically smaller than those in the
#bladder
& should not be confused with infiltrating
#urothelialcancer
- tangential sectioning can exacerbate the challenge!
Metanephic adenoma of
#kidney
demonstrating a spectrum of architectural patterns including small acinar, tubular, papillary & associated with marked psammomatous calcification
#gupath
1/2
With
#USCAP2023
approaching, I have been conversing with
@MSKPathology
fellows about how to make the most of the meeting
Thought I would share some ideas here (thread🧵):
1. Large professional mtgs can be overwhelming & IMO, require a strategy in order to maximize gains
👇🏻 1/
Incidental finding in a pelvic lymph node at cystectomy
🌟ENDOSALPINGIOSIS: note the cuboidal & ciliated lining epithelium
#beautyinbenign
#gynpath
#gupath
Excited to begin PGY 22 & Year 17
@MSKPathology
- grateful to learn from & be supported by amazing colleagues, friends, & especially family
Special shout-out to the love of my life, Dr. Chaya Fine, on our 25th anniversary celebration (6/30)
Silver ✔️ next 🥅 = gold :)
Not your typical lesion to begin the day (a case in 3 tweets) - Bladder paraganglioma - classic "zelballen" morphology, vascularity and
#IHC
profile: chromoganin/INSM (+)
#gupath
#bladder
#endocrinepath
1/3
Pagetoid spread of UROTHELIAL CARCINOMA IN SITU
Note the abrupt interface of DISORDER (architecture & cytology) with normal urothelium
#gupath
#bladdercancer
Central Zone glands
#prostate
🌉complex architecture
🌉stratified eosinophilic cytoplasm
🌉prominent basal cell layer
🌉intra-luminal bridges ("Roman arches")
🌉mimic high grade PIN
🌉Rule of 👍🏻: in NB from mid-base, have higher threshold for HGPIN & r/o normal anatomy!
#gupath
May is
#bladdercancerawarenessmonth
- important to recognize lesions which mimic
#bladdercancer
Nephrogenic metaplasia/adenoma:
- various architectures (papillary, tubular/glandular, vascular-like...)
- cuboidal to hobnail nuclear features
- prominence of basement membrane
#bladdercancer
w/features diagnostic of superficial pT1 (lamina propria) invasion
▶️ small, irregular nests
▶️ "paradoxic differentiation"=tumor cells more pink cytoplasm than in non-invasive component
▶️ retraction
▶️ loss of capillary network/"cuff" around tumor nests
#gupath
Although uncommon, sarcomatoid differentiation = poor prognostic sign in chromophobe renal cell carcinoma
'islands' of chromophobe RCC amidst a 'sea' of sarcomatoid morphology [pics]
Incidence in a large series:
#gupath
#KidneyCancerAwarenessMonth
Personal moment: so incredibly proud of Dr. Chaya Fine, Director of Science &
#STEM
Education and 20 Years
@SARacademy
🐝 and my most amazing life partner being honored as Faculty Awardee - so thrilled to be at
@americandream
#thewonderofitall
Clear cell-papillary renal cell carcinoma w/classic alignment of nuclei / CK7 diffuse (+) / CA-IX (+) in a "cup-like" (incomplete membranous) pattern - as first described here:
#kidneycancer
#gupath
Prominent example of ejaculatory duct/seminal vesicle amyloid in a
#prostate
needle biopsy specimen - associated with aging, not a systemic disease process
#gupath
Newer insights in Renal Cell Carcinomas w/ "clear cell" features have yielded distinctive entities incl. clear cell-papillary RCC and an emerging group of tumors =
RCC w/prominent fibromuscular stroma
#gupath
#kidneycancer
#KidneyCancerAwarenessMonth
1/
Evolution in
#prostatecancer
(PCa)
What happened to Gleason grade/pattern 1 & 2?
[depicted below]
Multifactorial:
i. In 1990s: PCa was increasingly diagnosed on NBx="circumscription" required for these patterns was more challenging
#ProstateCancerawarenessmonth
#gupath
1/n
PROSTATIC DUCTAL ADENOCARCINOMA: 1/
▶️ large gland variant of
#prostatecancer
▶️ may mimic papillary urothelial carcinoma on cystoscopy
▶️ typically seen together with usual acinar adenoCA
▶️ papillary & cribriform/papillary architecture (see pic)
#gupath
Four different views of the ejaculatory duct "complex" in mid-base prostate; note the large # of slit-like lymphovascular spaces - an excellent spot to identify LVI
#gupath
#prostatecancer
Classic example of Prostatic Ductal Adenocarcinoma in transurethral resection
Note prominent papillary architecture w/stratified columnar cells [best in lower R], underlying the urothelium [best in upper R]
Grading: akin to GS 4+4=8 in this example
#prostatecancer
#gupath
Atypical-appearing, yet benign changes in
#prostate
post-radiation therapy:
☢️ peri-glandular fibrosis
☢️ nuclei w/different shapes and sizes, including elongated/bizarre/degenerative-appearing
☢️ reactive nucleoli, at least some in basal cells
☢️ eosinophilic cytoplasm
#gupath
Sarcomatoid Differentiation in
Chromophobe Renal Cell Carcinoma
✨Islands of ChRCC surrounded by sarcomatoid growth (best seen in R side pic)
#gupath
#kidneycancer
Let's tackle mucinous fibroplasia in
#prostatecancer
▶️represents organization of extravasated mucin from PCa glands
▶️occasionally seen together (see PIC)
▶️ultrastructure: composed of collagen fibrils; hence, also known as "collagenous micronodules"
#gupath
@Gleason4plus5
1/
Dense pink secretions & blue mucin are intraluminal contents (along w/crystalloids) that may identify foci suspicious for
#prostatecancer
, BUT may also be seen in a host of benign mimics, seen here in partial atrophy with attenuated cytoplasm & lacking prominent nucleoli
#gupath
Seminoma extensively involving RETE TESTIS
Pitfall: ubiquitinated protein accumulation in rete testis can mimic 'hyaline globules' seen in yolk sac tumor
#gupath
#testicularcancer
Pitfall in interpretation: in this oncocytic tumor, displaying low grade nuclear features and architecture suggestive of oncocytoma (in other foci, nuclear membrane irregularity, etc. beyond that typically seen in oncocytoma) - diffuse 2-3+ TFEB nuclear labeling 🚨🚨🚨 👇🏻
#gupath
Large gland lesion in the
#prostate
- presume basal cell markers are (+) - what is your diagnosis?
🔥 Extra Credit: explain your rationale
✳️ Poll in Tweet below
#gupath
1/
Overt Transition of Low-Grade to High-Grade
Non-Invasive Papillary Urothelial Carcinoma
(uncommon in my experience)
#gupath
✨abrupt changes in cellular polarity
✨marked differences in nuclear size, shape, & color
✨in this ex.: accompanied by increased mitotic figures
FH-deficient Renal Cell Carcinoma
🧬common in context of germline mutations/deletions of Fumarate Hydratase (chr. 1q43)
🧬part of Hereditary Leiomyomatosis-RCC Syndrome along with cutaneous/uterine leiomyomas
📊typically aggressive
#gupath
#KidneyCancerAwarenessMonth
1/
Real-world example of
#prostatecancer
with profound treatment effect in a patient who received
#radiationtherapy
☢️ note poorly formed gland & single cell architecture w/bubbly or foamy cytoplasm and small nuclei w/nucleoli; such cases are NOT graded
#gupath
This one’s for Jerad
@JMGardnerMD
- May 25th (1812) - birthday of Italian anatomist Filippo Pacini who discovered Pacinian corpuscles (seen below) in skin and occasional other sites -
#pathology
WHO/ISUP Grade 4 in Clear Cell Renal Cell Carcinoma: image on L demonstrating extreme pleomorphism, image on R demonstrating rhabdoid features
#kidneycancer
#gupath
OK
#gupath
interested folks - how would you evaluate this focus of
#ProstateCancer
- small well formed glands? poorly formed glands? 3+3=6? 3+4=7? any features that give you pause?
Dispersed PARAGANGLIA in lymph node dissection for
#kidneycancer
Small nests of cells with bland nuclei & variegated amphophilic/basophilic (purple-ish) to clear cytoplasm
Often seen in proximity to nerves
#PitfallAlert
#gupath
CAUTION: do not confuse w/metastatic carcinoma
May the fresh and sparkling lights of Chanukah 🕎 illuminate these dark times & inspire our minds, hearts, and acts of kindness as they have for millennia
#ChagChanukahSameach
to all those celebrating 🎉 🕯️
Flat carcinoma in situ of bladder - including: a) involvement of squamous metaplasia , b) a field with overlying umbrella cell layer, c) a contrast with normal von Brunn nest and d) hi power view of nuclear irregularity - this one's for you
@evacomperat
#gupath
#bladdercancer
For many yrs, Papillary RCC classified as Type 1 or 2
**In WHO GU 2022, division eliminated secondary to many "Type 2" cases = molecularly-defined RCCs, including translocation-assoc., FH-deficient RCC, etc.
#gupath
#KidneyCancerAwarenessMonth
#OrangeUp
Feeling privileged, blessed & thankful to have received 1st dose of
#vaccine
💉- thank you to
@sloan_kettering
&
#msknurse
Marisa for making the process easy & efficient -
#igotmyshot
- encourage all to do so as well!
🚨🚨Pitfall alert: bladder biopsy with
#prostatecancer
undermining benign urothelium
NOT to be confused with urothelial carcinoma in situ involving von Brunn nest
#gupath
Morphology: note enlarged uniform nuclei with prominent nucleoli
#IHC
: NKX3.1 (+) GATA3 (-)
✨✨CLASSIC example of flat urothelial carcinoma in situ involving a von Brunn nest
#gupath
Note circumscription of nests & the capillary network surrounding the basement membrane, indicating a non-invasive process - clinically, classified as NMIBC
#bladdercancer
It’s almost time ✈️ NYC ➡️
#NOLA
for
#USCAP2023
- looking forward to a wonderful week of learning, (re-) connecting, & tweeting the meeting
@MSKPathology
Appendix testis (normal structure) - note the transition from simple mesothelial lining of the testicular tunica to the ciliated columnar epithelium of the appendix
#gupath
#testis
#beautyinB9
We typically urge caution in diagnosing
#prostatecancer
in the presence of inflammation; in unusual cases, cancer is seen in a background of a dense inflammatory infiltrate - using
#IHC
is useful & often necessary to make a definitive diagnosis in this scenario
#gupath
Prominent intraductal carcinoma of the prostate in a radical prostatectomy specimen post-androgen-deprivation therapy: note cytoplasmic clearing & prominent nucleoli in the setting of readily-evident basal cells
#gupath
#prostatecancer
Challenging "brass knuckles" pattern of perineural invasion in
#prostatecancer
- the proclivity of PNI to distort glandular architecture may lead to interpretive differences as pattern 3 vs. pattern 4
#gupath