Dr. Shameem Shariff

MONTHLY QUIZ

Dr. Shameem Shariff, MD, PhD
Formerly, Professor and Head,
Dept. of Pathology, MVJ Medical College and Research Hospital &
St. John’s Medical College,
Bengaluru, India
www.shameempathology.com

Ans to previous : (December 2024)

SEGA ie., Subependymal giant cell astrocytoma.

Ans to previous (December 2024):

Formalin fixation
1. Place the specimen in a spacious container ( labelled with patient ID and specimen type) with fixative, ensuring that the specimen is fully submerged.
2. Section the specimen across if necessary to ensure better fixation.
3. Use a fixative-to-specimen ratio of at least 10 to 20 :1 to ensure thorough
penetration .
4. Fixation time : for small specimens 8-12 hours and for larger specimens 24 hours at least.
5. Preparation of 10% formalin : to 10 ml of commercial formalin (40%) add 90 ml of distilled water.

Ans to previous : (November 2024)

Adenocarcinoma lower lip, Glandular pattern +ve; Vacuolated cells with intracellular secretions .

Fig above shows result of PAS stain with magenta stained intracellular secretions. The carcinoma probably arose from the minor salivary glands in the lower lip.

Ans to previous (November 2024):

1. Microscopic examination of a drop of secretions.
2. KOH preparation: 20% KOH solution can be used on many types of samples, including skin scrapings, hair, cervical secretions & sputum.
3. Calcofluor white stain: this binds to fungal elements in a sample and fluoresces under UV light, making them visible the slide.

Ans to previous : (October 2024)

Renal Cell carcinoma -clear cell type.
The 2 factors at gross with a poor prognosis are the size of tumour ie 12 cms and the presence of necrosis. Presence of necrosis is considered an independent prognostic factor. The grade of tumour in the figs shown was given as 2 and stage was T2.
Grading of RCC :
A modified grading system for renal cell carcinoma (RCC) that incorporates tumor necrosis is as follows:
• Grade 1: ISUP grade 1 and non-necrotic ISUP grade 2
• Grade 2: Necrotic ISUP grade 2 and non-necrotic ISUP grade 3
• Grade 3: Necrotic ISUP grade 3 and non-necrotic nonsarcomatoid/rhabdoid ISUP grade 4
• Grade 4: Necrotic ISUP grade 4 and sarcomoatid/rhabdoid features
Tumor necrosis is an independent predictor of adverse outcome in RCC. This modified grading system outperforms the ISUP grading system and shows significant differences in survival between each grade.

Staging of RCC:

Ans to previous (October 2024):

a) Renal biopsies for staining of antibodies such as IgG, IgM, IGA, fibrin etc b) Detection of auromine labelled acid fast bacilli.c) Antinuclear antibodies detection in SLE and other autoimmune disorders; ANCA antibodies. d) Salt split immunofluorescence technique to differentiate pemphigus from epidermolysis bullosa acquisita e) In the detections of specific antigens, proteins, viruses, parasitic infections etc .f) Antinuclear antibodies detection in SLE and other autoimmune disorders; ANCA antibodies g) FISH to detect specific DNA segments h) Auto fluroscence in detection of formalin pigment and red fluorescence over green in neoplastic cancerous tissue.

Ans to previous : (September 2024)

Malignant melanoma. Perl’s stain to exclude haemosiderin and Schmorl’s stain, stains the pigment blue-green. Immunohistochemical markers for melanocytic differentiation, such as melan A, MART-1 (melanoma antigen recognized by T cell 1), HMB 45 (human melanoma black 45) (all three show cytoplasmic positivity), and S-100 (nuclear positivity) are often positive in melanocytic tumors.
The pigment is normally found in melanocytes in the skin, substantia nigra and eye.

Ans to previous (September 2024):

DOPA (deoxyphenylalanin) reaction is used in the diagnosis of amelanotic melanoma where pigment production is invisible grossly. It is a distinctive enzyme reaction and stains the invisible pigment of amelanotic melanoma, as the DOPA substrate is acted upon by DOPA-oxidase in the melanin-producing cells to produce a brownish black deposit. It differentiates undifferentiated carcinoma from amelanotic melanoma.

SEPTEMBER 2024

Quote : It is never too late to be what you might have been – George Eliot

Ans to previous : (August 2024)

The gross and microscopy (figs 1 to 4) show chronic non specific pyelo-nephritis with marked hydronephrosis. Note periglomerular fibrosis and dilated tubules.

Ans to previous (August 2024):

Ans to previous (August 2024):

Technique Ans : Fig 1 shows nuclear positivity in a dilated benign duct of a breast lesion (Maybe carcinoma in the vicinity. Breast tissue in section acts as internal control). It shows nuclear positivity.

Immunohistochemistry is increasingly used in the assessment of markers for breast cancer prognosis. If the result is positive for estrogen or progesterone receptors, it means that the patient is ER or PR+ and will respond to hormone therapy.

The most common method used in grading this positivity is the H-score which takes into consideration the staining intensity in conjunction with the percentage of cells staining positively in breast carcinoma.

A common scoring system is the Allred Scoring System. A similar approach to Allred score is demonstrated in so-called “quick score” system, with the differences in assigned values from 1 to 6 in proportion category A (of positivity) ; (1 = 0-4%, 2 = 5-19%, 3 = 20-39%, 4 = 40-59%, 5 = 60-79%, 6 = 80-100%) and 3 categories for intensity of staining; also multiplication is recommended instead of addition (as in the Allred score) for processing of the final score range. ( Detre S, Saclani Jotti G, Dowsett M. A “quick score” method for immunohistochemical semi-quantitation: validation for oestrogen receptor in breast carcinomas. J Clin Pathol. 1995;48:876–878. doi: 10.1136/jcp.48.9.876.)

Fig 2 : The marker used is Her2 new done routinely in breast carcinoma. Shows a 3+ positivity in the membrane of tumour cells. It is on the membrane surface that this receptor is located and positivity is read on the membrane.

IHC results for HER2 are reported as 0, 1+, 2+, or 3+. A score of 0, 1+, means the tumor is HER2-negative. A score of 2+ means the results are unclear and another test is needed, such as FISH. A score of 3+ means the tumor is HER2-positive.

One in five breast carcinomas show excess Her2 new expression.

Ans to previous (August 2024)

Ans is :
1. increased protein, increase in cells, specific gravity greater than 1.020

AUGUST 2024

Quote : The secret of getting ahead is getting started. Mark Twain

Ans to previous : (JULY 2024)

Tru cut biopsy shows features consistent with a benign phylloides tumour.

Fig 1 : Section shows fragments of stromal elements. The lower 2 fragments are cellular but no pleomorphism of the stromal cells is seen. Fig 2 shows a closer view with epithelial cells and stromal elements both of which are bland.

Figs 1 and 2 : show FNAC appearances of the breast mass 5cms in size before a true cut biopsy was done. fig 1 shows a sheet of benign appearing ductal epithelial cells as well as stromal fragments and fig 2 a high power view of both elements; suggesting a bimodal patterned lesion favouring phylloides tumour.

Ans to previous (JULY 2024):

ACS recommendations for detection of early breast cancer in women with ‘average risk’:

– Women between 40 and 44 have the option to start screening with a mammogram every year.
– Women 45 to 54 should get mammograms every year.
– Women 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms. Screening should continue as long as a woman is in good health and is expected to live at least 10 more years.

(All women should understand what to expect when getting a mammogram for breast cancer screening )– what the test can and cannot do. Clinical breast exams are not recommended for breast cancer screening among average-risk women at any age.

ACS recommendations for detection of early breast cancer in women with ‘high risk’: Women who are at high risk for breast cancer based on certain factors should get a breast MRI and a mammogram every year, typically starting at age 30. This includes women who:

– Have a lifetime risk of breast cancer of about 20% to 25% or greater, according to risk assessment tools that are based mainly on family history (see below)
– Have a known BRCA1 or BRCA2 gene mutation (based on having had genetic testing)
– Have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves
– Had radiation therapy to the chest before they were 30 years old
– Have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.

Ans to previous (JULY 2024)

The diagnostic categories of the National Cancer Institute recommendations and their corresponding numerical codes in breast FNAC reporting are: Inadequate/insufficient (C1); Benign (C2); Atypical – probably benign /indeterminate (C3); Suspicious of malignancy (C4) and Malignant (C5). The answer here is iii.