UPDATE: SurgicalDiagnostic Pearls for the Practicing Pathologist

Friday, October 7, 2016 Aria® Resort & Casino • Las Vegas, Nevada

Educational Symposia TABLE OF CONTENTS

Friday, October 7, 2016 The Trouble with Fat: Diagnostic Issues in Well-Differentiated Lipomatous Tumors (John R. Goldblum, M.D.)...... 1 Practical Approach to Melanocytic Tumor (Steven D. Billings, M.D.)...... 15 Reporting of Prostate in Needle Specimens: Gleason and More (David J. Grignon, M.D., FRCP(C))...... 45 Unraveling the Mesenchymal Madness in Gynecologic Tumors (Kristen A. Atkins, M.D.)...... 73

REGISTER TODAY - 2017 Pathology Symposia 1 2 The Trouble With Fat: Diagnostic Issues in Well-Differentiated Lipomatous Tumors

John R. Goldblum, M.D.

Chairman, Department of Pathology, Cleveland Clinic Professor of Pathology, Cleveland Clinic Lerner College of Medicine Cleveland, Ohio

Benign Lipomatous Tumors Lipomatous Tumors of Intermediate • •

• • Atypical lipomatous tumor • • (Well-differentiated ) • Myolipoma • Spindle cell / •

Liposarcoma Malignant Lipomatous Tumors • Atypical lipomatous tumor (well-differentiated liposarcoma)

• Dedifferentiated liposarcoma • lipoma-like • • sclerosing • Round cell liposarcoma • inflammatory • spindle cell • Pleomorphic liposarcoma • dedifferentiated • Mixed-type liposarcoma • Myxoid / round cell liposarcoma • Liposarcoma, NOS • Pleomorphic liposarcoma

3 Pseudolipoblasts • Fat

• Hibernoma cells

• Silicone reaction

• Signet ring cells

• Fixation artifact

• Neoplastic fat infiltration

Well-differentiated Lipomatous Tumors • The most common consultation we receive • Pleomorphic/ vs ALT • Intramuscular lipoma vs ALT • Lipoma with fat vs ALT

• Good rule: the larger and deeper the lesion, the more likely it is to be an ALT (but there are exceptions)

• Deeply located benign tumors (intramuscular lipoma) • Superficial ALT

4 5 CD34

CD34

Spindle Cell / Pleomorphic Lipoma Pleomorphic Lipoma • Well-circumscribed subcutaneous mass

• Shoulder, neck, back • Atypical lipomatous tumor • Striking male predominance

• No recurrence / metastasis • Pleomorphic • CD34-positive

• Common cytogenetic abnormality (16q¯, 13q¯)

6 ALT/WDL: A Historical Perspective Evans (1979) Evans (1979)

Recur Dediff Mets Died Subcutis (9) 0 0 0 0 Subcutis Deep Retroperitoneum

Deep soft tissue (13) 69% 0 0 0

Retroperitoneum (8) 62% 0 0 37% Atypical lipoma Atypical intra- WDL muscular lipoma

ALT/WDL: A Historical Perspective Weiss (1992) Weiss & Rao (1992)

Recur Dediff Mets Died Subcutis Deep soft tissues Retroperitoneum

Deep soft tissue 43% 6% 0% 0% (46) Atypical lipoma WDL WDL Retroperitoneum 91% 17% 17% 33% (23)

Weiss SW et al, AJSP 1992

ALT/WDL: Lumper or Splitter?

• Lumpers • Call all tumors (regardless of site) ALT

• Call all tumors (regardless of site) WDL • Splitters • Superficial (subcutis) Atypical lipoma

• Deep (deep soft tissue/retro) WDL

* Requires communication and understanding between pathologist and surgeon/oncologist!

7 When To Suspect ALT/WDL • Large and deep fatty tumor (when it comes in buckets!)

• Retroperitoneal fatty tumor (with rare exceptions)

• MRI heterogeneity (surgeon is suspicious)

• Fibrous bands

• Atypia (hyperchromasia) identified at low power

*Don’t look for lipoblasts!!

Courtesy of Dr. F. Pédeutour MDM2 amplification

8 Problematic Lipomatous Tumors MDM2 FISH: Indications % Cases • Tumor size > 10 cm (62%) • Equivocal atypia (48%) • Deep location (28%) • Recurrence (11%) • Other (clinical suspicion) (4%)

• Multiple indications 48% • Single indication 52%

MDM2 Clay MR et al. AJSP, 2015

Problematic Lipomatous tumors MDM2 FISH: Multi vs Single Indication Problematic Lipomatous Tumors Recommendations for MDM2 FISH Indications ALT PL/SCL Lipoma Multiple (144) 65 (45%) 15 (11%) 64 (44%) • Recurrent well-differentiated lipomatous tumors

Single (157) 43 (27%) 36 (23%) 79 (50%) • Lipomatous tumors with equivocal cytologic atypia

• Retroperitoneal, intra-abdominal and pelvic tumors • Combo of size >10 cm, deep location and equivocal atypia was almost always ALT (13/14 cases) • Deep extremity tumors >10 cm in patients >50 years

• Size >10 cm and deep location almost always ALT

Clay MR et al. AJSP, 2015 Clay MR et al. AJSP, 2015

Problematic Lipomatous Tumors Pleomorphic Lipoma vs ALT

Cases That May Not Require FISH PL ALT/WDL

• Superficial tumors Atypical cells Yes Yes

• Lipomatous tumors of the hands and feet Floret cells characteristic sometimes

• Tumors in unusual locations with no other indicators Ropey collagen Yes No

• Small retroperitoneal tumors with no other indicators CD34 Yes Rare cells (requires validation in larger series of cases) MDM2 ampl No Yes

Dedifferentiation No Sometimes Clay MR et al. AJSP, 2015

9 ALT / WDL Low-grade sarcoma (no metastatic capability)

incomplete excision complete excision

Local recurrence Cured!

Tumor progression

Metastasis

Differential Diagnosis

• DDL without sampled low- grade (WDL) component

• DDL with no residual low- grade (WDL) component (overgrowth by high-grade component)

• Non-DDL pleomorphic sarcoma • Does it matter? • How can you tell? Retroperitoneal Mass

10 Dedifferentiated Liposarcoma Dedifferentiated Liposarcoma McCormick et al: 32 cases Henricks et al: 155 cases

• Location: 19/32 (59%) in retroperitoneum or Site Recurrence Mets Died of Median f/u paratesticular Retroperitoneum (88) 41 (47%) 16 (18%) 30 (34%) 2.8 yrs

• De novo dedifferentiation in 30/32 (94%) Accessible deep soft tissue (27) 9 (33%) 4 (15%) 3 (11%) 3.5 yrs • Follow-up: 3 mos – 33 years (mean: 5.6 years) Total (130) 53 (41%) 22 (17%) 36 (28%) 3 yrs • Metastasis in 4/27 (15%)

Henricks et al. AJSP, 1997 McCormick D et al AJSP, 1994

Dedifferentiated Liposarcoma Dedifferentiated Liposarcoma Deep Thoughts MDM2/CDK4

Amplification IHC • DDL has a lower metastatic rate than other Diagnosis MDM2/CDK4 (a-CGH/RT-PCR) MDM2 CDK4 Both pleomorphic as a whole Dediff Liposarcoma 53/55 (96%) 52 51 49

Simulators • Therefore, it is important to distinguish DDL from • Myxofibrosarcoma 8/13 (62%) 8 3 2 other pleomorphic sarcomas, including UPS • 5/32 (16%) 2 1 1 • MPNST 2/6 (33%) 6 1 1 • Most (if not all) UPS (“MFH”) of the retroperitoneum • “MFH” 3/39 (8%) 3 1 1

are actually DDL

Binh MD et al AJSP, 2005

Well-differentiated Lipomatous Tumors Liposarcoma Cytogenetics Category Cytogenetics

Lipoma 12q, 6p, 13q ALT/WDL Ring/giant marker chromosomes (12q13-15) Hibernoma 11q Dedifferentiated Additional complex Lipoblastoma 8q aberrations

Spindle / pl lipoma 16q, 13q Myxoid/round cell t(12;16)(q13;p11)

ALT / WDL ring chromosomes (12q) Pleomorphic Complex aberrations

11 Problematic Lipomatous Tumors MDM2 FISH: Tumor size > 10 cm Final Dx based on FISH No. cases (%) ALT 68 (36%) PL/SCL 14 (7%) Lipoma 105 (56%)

• 51/68 ALTs had at least one other indication for FISH • 17/68 cases tested and proved to be ALT based on size alone • All >50 yrs • All in deep soft tissues of extremities • No tumor in superficial soft tissue tested for size alone was ALT

Clay MR et al. AJSP, 2015

Problematic Lipomatous Tumors Problematic Lipomatous Tumors MDM2 FISH: Equivocal Atypia MDM2 FISH: Deep Location (retro/abd/pelvic)

Final DX based on FISH No. cases (%) Final DX based on FISH No. cases (%) ALT 72 (50%) ALT 30 (35%) PL/SCL 44 (30%) PL/SCL 6 (7%) Lipoma 29 (20%) Lipoma 50 (58%)

• Most common sole indication to FISH (72 cases) • 9 cases in which deep location was sole indicator: all • 7 cases in hands and feet all classified as PL/SCL benign

Clay MR et al. AJSP, 2015 Clay MR et al. AJSP, 2015

Problematic Lipomatous Tumors Problematic Lipomatous Tumors MDM2 FISH: Recurrence MDM2 FISH: Unusual Features (n=12)

• Unusual location (e.g. epiglottis)* Final Dx based on FISH No. cases (%) • Clinical concern by surgeon ALT 18 (55%) PL/SCL 3 (9%) • Worrisome imaging findings Lipoma 12 (36%) • Unusual morphologic features (e.g. myxoid features)

• All recurrent superficial tumors were benign (n=7) *only case which proved to be ALT

Clay MR et al. AJSP, 2015

Clay MR et al. AJSP, 2015

12 Liposarcoma

Category Cytogenetics

ALT/WDL Ring/giant marker chromosomes (12q13-15)

Dedifferentiated Additional complex aberrations

Myxoid/round cell t(12;16)(q13;p11)

Pleomorphic Complex aberrations

13 14 15 16 General Rules for Melanocytic Tumors • Low power examination – Symmetry Practical Problems in • Junctional component • Dermal component Melanocytic Tumors • Pigmentation • Steven D. Billings • Medium Power examination – Circumscription Cleveland Clinic, Cleveland, OH – Growth pattern [email protected] • : nested vs. single cell • : regular nests vs. irregular nests or confluent • Maturation: do the melnocytes get smaller deeper in the dermis?

General Rules for Melanocytic General Rules for Melanocytic Tumors Tumors • High power examination • The best special stain is H&E – Upward (pagetoid) spread of melanocytes – Levels often helpful – Cytology • Do not sign out difficult cases when you • Nevoid are tired • Epithelioid – Friday afternoon rule • Spindled • Pleomorphic • Do not be a hero – Dermal mitotic activity – Show cases to colleagues – Get consults when necessary

Histology Issues

• Orientation important for accurate diagnosis • Embedding is more important than cutting • Beware of fixation artifacts

17

• Beware of keratinocytes with haloes – Fixation artifact – Resemble pagetoid melanocytes – Key: where is the cytoplasm? • Halo around nucleus without cytoplasm = keratinocyte • Halo around nucleus with attached cytoplasm = melanocyte

Margin Assessment

• Reactive melanocytic common • Increased number of melanocytes ≠ positive margin • Positive margin: – Contiguous proliferation of melanocytes – Nests – Extension far down adnexal structures – Prominent pagetoid spread

18 Margin Assessment

• Melanocytic hyperplasia does not increase risk of local recurrence • Do not overcall

Dysplastic Dysplastic nevus

• Clinical features • Clarks nevus, dysplastic nevus, nevus – Large (> 6mm), irregular shape, ill-defined with architectural disorder, atypical nevus border, variable color • Clinically irregular but fall short of • Most: sporadic • Minority: dysplastic nevus syndrome – Autosomal dominant inheritance – Numerous (>100) dysplastic nevi – Increased risk of melanoma – Family history of melanoma

Dysplastic nevus

• Architectural features – Relatively symmetric – Bridging of nests – Lamellar fibroplasia – Lentiginous melanocytes – Irregular nests – Irregular placement of nests – Variable inflammatory infiltrate with melanophages – Focal upward spread acceptable, but should not be prominent

19 Mild Dysplastic Significance nevus: grading Feature Mild Moderate Severe • Benign

Nuclear size Similar to 1-2X basilar > 2X basilar Moderate • Controversial basilar keratinocyte keratinocyte keratinocyte Pleomorphism Mild Moderate Severe • Patients with dysplastic nevus syndrome have increased risk of melanoma Chromatin Hyperchromatic Hyperchrom Vesicular to vesicular • Patients with >5 dysplastic nevi have

Nucleolus Absent or small Absent or Prominent increased relative risk of melanoma small Severe

Cytoplasm Little Little to Often moderate abundant

20 My approach

• I am not dogmatic • I grade dysplastic nevi Grading does it matter? • For lesions with moderate to severe atypia, I comment on margin status of Some say yes, some say no • If I am significantly concerned, I ask for conservative re-excision

Why?

• Up to 36% of have an adjacent dysplastic nevus (usually with moderate to severe atypia)

Practical issues

• Lesions often partially sampled • Some days you are off your game • If it is a melanoma that I missed, it is likely to be in a dysplastic nevus with moderate to severe atypia

21 Recurrent (Persistent) Nevi

• Present as recurrent pigmented lesion or change in incompletely excised nevus Tricky Melanocytic Lesions • Usually in setting of previous shave biopsy or trauma – Original biopsy may show incomplete or apparently complete removal • Trauma prone areas – Lower legs – Where clothes rub – Face

22 Recurrent Nevi Recurrent Nevi

Microscopic features • Practical Tips • Effacement of normal rete peg pattern – Architecturally worrisome only over • Dermal scar – Bland nuclei (usually) – Dermal component bland • Irregular junctional melanocytic proliferation – History/location – Asymmetric – Absence of history or benign nevus, be careful: – Single cells • Consider descriptive diagnosis of atypical melanocytic – Pagetoid spread proliferation over scar, see note – Cytologically bland (usually) • Note: In the appropriate clinical context this could represent a recurrent nevus, but a regressed melanocytic lesion or – Limited to area over scar regressed melanoma could be considered.

Nevi of “special sites” Nevi of “special sites”

• Scalp, including hairline • Common theme to special site nevi: • Ear • Increased architectural disorder • Intertriginous areas – Odd placement of nests • Genital – Less symmetry • Breast – Some single cell growth pattern – Some upward migration • Ankles • Increased cytologic atypia • Acral skin

23 Atypical Genital Nevi Atypical Genital Nevus

• Clinical Features • Relatively symmetric but with other worrisome – Young women (mean age 20s) features • Can occur in children or older adults • Lentiginous and nested junctional component, – Vulva and anatomic milk line (breasts, axillae, often with retraction spaces periumbilical, groin) • Epithelioid melanocytes in junctional component – Average size 5-6 mm • Pagetoid spread often present (~20%) but focal – Approximately half clinically atypical • Atypia: mild (20%), moderate (64%), severe – Labia majora, mons pubis, labia minora, (20%) clitoris, perineum

Atypical Genital Nevus

• Dermal atypia (39%) but restricted to upper dermis • Dermal mitotic figures (7%) • Dermal fibrosis (41%) • All lesions had maturation • Large common dermal nevus component in almost half of cases

24 Vulvar melanoma

Differential Dx: Vulvar Melanoma Acral Nevus

AGN Vulvar melanoma • Clinical features – Fairly common: ~5% of Caucasians • Younger patients • Postmenopausal – Usually relatively small • Nested • Single cell pattern • Microscopic features – Symmetric • Symmetric • Asymmetric – Single cell growth pattern common • Pagetoid spread focal • Pagetoid spread – Upward spread of melanocytes prominent – More prominent over sulci • Maturation – Rare atypical cells in junctional component • Absent to rare MFs • No maturation – Often poorly circumscribed • Dermal MFs – Dermal component bland • Differential diagnosis: acral lentiginous melanoma

25 Acral Lentiginous Melanoma

• Clinical Features – Older patients 7th and 8th decades – Rare <30 years of age – Usually large (1-3 cm) – Irregularly pigmented – Foot > hand – Most common form of melanoma in darker pigmented people

Acral Lentiginous Melanoma Acral Lentiginous Melanoma

• Microscopic features • Microscopic features – Asymmetric – Skip areas frequent – Single cell growth pattern – Biopsies not always diagnostic (especially – Irregular nests from lesion edge) – Variable upward migration (more prominent in • Consider re-biopsy if clinically suspicious older lesions) – Nests often absent in early lesions – Pagetoid spread > than acral nevi – Dermal component can be relatively bland – Hyperchromatic nuclei with haloes – Mixed types common (superficial spreading) (especially dorsal surface)

26 Acral nevus vs. Acral melanoma

Nevus Melanoma • Younger patients • Older patients • Small (<1 cm) • Larger (>1 cm) • Nuclei less • Angulated hyperchromatic hyperchromatic nuclei • No pleomorphism • Pleomorphism • Single cell pattern on rete • Single cell pattern tips contiguous • Pagetoid spread more • Pagetoid spread central throughout • Dermal component bland • Dermal component with atypia

Nevi during hormonal states • Common nevi in pregnant patients or teenagers may have some atypia and rare mitotic figures • Low power features resemble conventional nevus Rasta no abide amputation. I don't allow a man to be dismantled.

27 Melanoma In Situ on Sun-damaged Skin ( Maligna) • Subtle on heavily sun damaged skin of • Incidence ~1% head and neck (lentigo maligna type) • More common in young patients • Contiguous proliferation of melanocytes • Head and neck and extremities • Focal nests • 80% one MF • Upward migration usually not prominent • 89% upper dermis • Atypia usually mild • Congenital or Spitz features

Melanoma in Situ (Lentigo Maligna) • Differential diagnosis – Pigmented – Solar lentigo

28 Melanoma In Situ on Sun-damaged Skin • Practical tips – Any contiguous proliferation of melanocytes or nests worrisome for melanoma in situ – Extension down follicles – Junctional dysplastic nevi uncommon in heavily sun-damaged skin of elderly patients – Immunostains can help distinguish pigmented AK from MIS (red chromogen can be helpful) • HMB45, S100, MiTF, SOX-10 (beware of pitfalls) • Beware Melan-A in inflamed skin

S100S100 Nevoid Melanoma

• Clinical features – May be innocuous – Verrucous to dome shaped • Microscopic features – Resembles nevus on scanning magnification HMB45HMB45 MiTF (SOX10) – Small epithelioid melanocytes – Subtle atypia – Mitotic activity – May have sheet-like growth

29 30 Nevoid Melanoma

• Outcome – Recurrence rate 50% – Metastasis 25-50% – Mortality ≥ 25% – Likely due to more advanced stage at presentation • Practical tips – Examine all nevi at least briefly at high power – Beware of nevi with sheet-like growth pattern

Clinical Features

• Approximately 4% of all melanomas Desmoplastic (Neurotropic) • Present in 6th to 7th decades Melanoma • Most commonly involve head and neck • Lower extremity tumors more common in women • More than half clinically amelanotic – Potential for delayed diagnosis – Clinically suspected in minority of cases

Histopathology

• Majority involve reticular dermis (Clarks level IV) or subcutis (Clarks level V) • Breslow level: 2.5->4 mm • Epidermal ulceration up to 25% – Potential confusion with scar • Hyperchromatic spindle cells – Rare cases with deceptively bland nuclei • Packeted arrangement

31

• Perineural invasion in 1/3 of cases – Breslow depth >1.5mm • Mitotic figures usually conspicuous • pigment absent to sparse • Admixed lymphocytic infiltrate • Overlying junctional atypical melanocytic proliferation (40-90%) • May have admixed conventional melanoma

32

• S100 and SOX-10 strongly positive • Melanocyte specific markers (e.g. HMB45) of limited utility (<5% positive) • Smooth muscle actin negative – Fibroblasts in stromal response positive • Usually cytokeratin and desmin negative – Rare cases with anomalous expression

Behavior Compared with Differential Diagnosis Conventional Melanoma • Higher rate of local recurrence (10-50%) • Malignant cutaneous spindle cell tumors – Sarcomatoid (CK+, – Secondary to infiltrative growth pattern S100-) – Neurotropism increases risk – (CK-, S100-) • Lower rate of lymph node metastasis • Desmoplastic Spitz • Comparable rate of visceral metastasis • Hypopigmented blue nevus • MPNST • Overall survival similar to or better than conventional melanoma

Dermal Pleomorphic Spindle Cell DM vs. AFX vs. SSCC Tumor Differential Diagnosis DM AFX SSCC • The (un)Holy Trinity – Sarcomatoid (spindle cell) squamous cell Clinical H&N H&N Variable

carcinoma Packeted, Storifom, Pattern Storiform – Desmoplastic/spindle cell melanoma Short fasc. fascicles Pleo- Pleo to – Atypical fibroxanthoma/superficial Cytology Spindled morphic spindled undifferentiated pleomorphic sarcoma S100-, CK-, S100-, CK+, Immuno S100+, CK- (pleomorphic dermal sarcoma) SMA -/+ SMA -/+ Atypical junctional No melanocytes. Clues epidermal AK or SCC Lymphoid component aggregates

33 Blue Nevus Family Blue Nevus Family: Histopathology

• Clinical features • Oval to spindled melanocytes – Present in childhood to middle aged • Mitotic figures absent – Pigmented lesions with blue-black color • No nuclear hyperchromasia – Flesh-colored (amelanotic blue • Absence of lymphocytic infiltrate nevus) • Absence of junctional component • May have perineural involvement • Positive for melanocytic specific markers

Amelanotic blue nevus HMB45 Blue nevus

Desmoplastic (Spitz) Nevus

• Clinical features – Young adults – Extremities • Microscopic Features – Wedge-shaped – Junctional component uncommon – Small nests and multinucleated cells in superficial aspects – Spindled to epithelioid, mild to moderate cytologic atypia – Absent mitotic figures (<1/20 HPF) – Absent inflammatory infiltrate – Immunoreactive for specific melanocytic markers

34 Spitz Nevus

• Clinical features – Young age (<20 years) • <20 think Spitz, >40 think melanoma – Usually <0.6 cm – Rapid growth followed by stable phase – Red to red-brown to dark brown – Head and neck, proximal extremities (in women esp. legs)

Melan-A

Spitz Nevus Typical Spitz Nevus

• Variants • Microscopic features – Typical – Symmetric • Junctional – Predominantly nested • Compound – Clefts overlying junctional nests • Intradermal – Epithelioid and spindled melanocytes – Pigmented spindle cell nevus (of Reed) – Kamino bodies (often) – Desmoplastic Spitz – Maturation – Absence of dermal mitotic figures • Rare superficial MFs may be seen

35 Pagetoid Spitz Nevus

• Young women • Lower legs most common site • Microscopic features – Relatively symmetric – Predominantly single cells – Prominent upward migration – Usually no dermal component (rare cases with focal superficial dermal involvement)

36 Pagetoid Spitz Nevus Spitzoid Melanoma

• Clinical presentation very important • Clinical Features (usually legs of young women) – Adults (can occur in children) – Not clinically distinctive • Small, symmetric • Microscopic features • Significant overlap with melanoma in situ – Can be similar to Spitz nevus • Symmetric • Recommend conservative but complete • Circumscribed excision • Epithelioid melanocytes • Clefts may be present • Rarely small Kamino bodies (not clusters) • Pagetoid may be absent

Spitzoid Melanoma

• Differences from Spitz nevi – Deep tumors: reticular dermis to subcutis – Solid sheets – Large nodules – Lack of maturation – Dermal mitotic figures – Increased pleomorphism at same latitude – Prominent nucleoli deep – Irregular pigment – Asymmetry and prominent pagetoid spread when present

37 Hantschke et al AJSP 2004;28: 1621-5 Spitz Nevus vs. Spitzoid Melanoma Spitz Spitzoid Melanoma • Symmetric • Symmetric or asymmetric • No consumption of • Consumption of epidermis epidermis • Nested • Sheets • Pagetoid spread (nests, • Pagetoid spread (single fewer single cells) cells > nests) • Epithelioid/spindled • Epithelioid/spindled • No dermal MFs • No individual cell necrosis • Dermal MFs • Kamino bodies (clusters) • Individual cell necrosis • No to rare Kamino bodies (no clusters)

38 Atypical Spitz Tumor Ki-67

• Traditionally wastebasket term for when • Spitz • Melanoma you cant decide • Low proliferative rate • High proliferative rate • Other choices: • 0-10% • 5-40% – Spitz tumor of uncertain malignant potential • Zonal (upper portion • Present at all levels (STUMP) of lesion) – Atypical Spitz nevus Caveats: – Atypical spitzoid melanocytic proliferation 1. Overlap 2. Lymphocytes Ki-67 positive • Subjective 3. Thin melanomas 4. Classic cases tested

p16 Cyclin D1

• Spitz • Melanoma • Spitz • Melanoma • Diffusely positive • Variably positive • 5-20% • 5-25% – 40-80% of cells – 0-40% of cells • Zonal restricted to • Throughout – Positive at all levels – Less staining in dermis upper dermis – Nuclei and cytoplasm – Cytoplasm – Loss of p16 in Spitz tumor raises concern Caveats: for spitzoid melanoma 1. Overlap Caveats: 2. Thin melanomas 1. Overlap 3. Classic cases tested 2. Thin melanomas 3. Classic cases tested

Immunohistochemical Stains Melanoma

• Approach with caution • Mutations in BRAF, KIT and NRAS • No magic bullet common • Beware of overlap • V600E BRAF mutation most common • Can be supportive in selected cases • Assays for these mutations not specific – For example: BRAF and NRAS mutations common in nevi and melanoma

39 Melanoma

• Genetic landscape more complex • Not driven by translocations or simple activating mutations • Melanoma associated chromosomal aberrations – Losses of chromosomes 6p, 8p, 9p and 10q – Gains of 1q, 6p, 7, 8q, 17q, and 20q

Comparative genomic hybridization • Not widely available • Takes weeks • Expensive • 4 probes: 6p25, 6 cent, 6q23, 11q13 – May not be covered by insurance • Criteria – >38% nuclei with > 2 signals for 11q13 or • Requires relatively high percentage of – >55% nuclei more 6p25 than 6 centromere or tumor cells (30-50% of cells assayed) – >40% nuclei with less 6q23 than 6 cent. or – Not good for small amounts of tumor or – >29% nuclei with > 2 signals for 6p25 heavily inflamed tumors • Sensitivity 87%; specificity 95% • Caveat: typical lesions Gerami et al. Am J Surg Pathol 2009;33:1146–1156

Atypical Spitz

• Homozygous 9p21 deletion – 3/3 patients DOD – 6/8 with advanced locoregional disease • 64 atypical Spitz tumors with 5 years • Multivariate analysis: adverse outcome uneventful follow-up – Mitotic rate p = 0.03 • 11 atypical Spitz tumors with aggressive – Homozygous 9p21 deletion p = <0.0001 course • Atypical Spitz with homozygous 9p21 deletion = form of spitzoid melanoma • Analyzed by FISH

40 • Compared melanoma with and without MYC amplification • 19/33 with MYC amplification developed metastases • 1/30 without MYC amplification developed metastases

New probe set FISH limits

• Sensitivity 94% • Technically challenging • Specificity 98% • Expensive equipment • Caveat: on validation set • Still difficult in thin melanomas • Limited availability • Less accurate in ambiguous tumors – ~50-70% – Sensitivity 70% in spitzoid melanomas – Specificity ~80%

41 Myriad myPath Melanoma

• RNA extracted from FFPE tissue • cDNA • Quantitative PCR • 23 differentially expressed genes • PCR

42 FISH vs. GEP FISH vs. GEP

• Limitation: based on H&E gold standard • Advantages GEP • Similar sensitivity and specificity – Less subjectivity (FISH algorithms are – At least with validation sets complex) – No issue with tetraploidy • Advantages – May be better on thin lesions – FISH: • Can look at specific subpopulations • Perhaps better for melanomas arising in nevi

FISH and GEP

• Both have potential adjunct role • Positive results helpful • Negative/indeterminate results less useful • Performance on histologically indeterminate lesions is somewhat limited, but probably better than immunohistochemistry

43 44 45 46 PROSTATE CANCER EPIDEMIOLOGY (2016)

REPORTING OF PROSTATE CANCER IN NEEDLE BIOPSY SPECIMENS: GLEASON GRADING AND MORE Siegel et al. CaA Cancer J Clin 66:7-30, 2016

PROSTATE CANCER EPIDEMIOLOGY (2016)

All races White Black

Stage at Diagnosis 5-year Relative Survival 2005 - 2011 2005 - 2011 Ann Intern Med 157:120-134, 2012 Siegel et al. CaA Cancer J Clin 66:7-30, 2016

“With the recent publication of its final Grade D recommendation against prostate-specific-antigen (PSA)-based screening, the influential US Preventative Services Task Force has effectively laid siege to prostate cancer early detection in the United States and threatens to condemn thousands of men with high-risk prostate cancer to slow, painful, and avoidable deaths.” Donald F. Gleason, 1920-2008

47 ORIGINAL GLEASON DRAWINGS ORIGINAL GLEASON DRAWINGS 1968 September 8, 1968

GLEASON GRADING ACTIVE SURVEILLANCE IN PROSTATE CANCER: ELIGIBILITY • Based on architecture

• Perceived as a continuum INSTITUTION GLEASON # POSITIVE % CORE SCORE CORES POSITIVE • Subjectivity in gray areas Hopkins ≤ 6 ≤ 2 ≤ 50% between grades MSKCC ≤ 6 ≤ 3 ≤ 50% • Recognizes heterogeneity of Schroder ≤ 6 ≤ 2 -- prostate cancer UCSF ≤ 6 ≤ 33% (min 6) ≤ 50% U Miami ≤ 6 ≤ 2 ≤ 20% • “Score” is based on recognizing Canary trial ≤ 7 (3 + 4) ≤ 33% -- a “primary” and “secondary” UK trial ≤ 6 or ≤ 50% -- grade and summing the two ≤ 7 (3 + 4) if > 65

GLEASON GRADING APPLICATION IN 18 GUAGE ISUP Consensus Conference 2005 NEEDLE BIOPSIES

Amin, Grignon, Humphrey & Srigley

Gleason Grading of Prostate Cancer: A Contemporary Approach (2004)

48 GLEASON GRADING GLEASON GRADE FROM HERE

NOT FROM HERE Use higher magnification to confirm a low power impression

And a good H&E helps! GLEASON GRADE 1

Circumscribed , almost exclusive to TZ Glands are uniform and round

49 GLEASON GRADE 1 GLEASON GRADE 2

Glands more variable in shape than grade 1 Increased stroma between glands Some infiltration at periphery

GLEASON GRADE 2 GS 2 + 2 = 4

GLEASON GRADE 2 Small focus of Grade 3 - Not grade 1 or 2

50 GLEASON SCORE 5 CONSENSUS STATEMENTS ON “Transition zone biopsies” LOW GRADE PATTERNS

• Gleason score 1+2=3 and 2+1=3 can be seen in TUR and RP material but are not to be diagnosed in needle biopsy • Gleason score 2+2=4 in needle biopsy very controversial • Consensus that this score should “rarely if ever” be made in needle biopsy material

CHANGE IN DIAGNOSTIC Prostate Biopsy Strategy MATERIAL OVER TIME

Schwartz K, Grignon D, et al. Urology 55:769, 1999

GLEASON GRADE 3 GLEASON GRADE 3

Well formed glands with infiltrative growth May be small, angulated or compressed Cribriform architecture with round nests

51 GLEASON GRADE 3 GLEASON GRADING CRIBRIFORM PATTERNS

Amin, Grignon, Humphrey & Srigley, 2004

GLEASON GRADING GLEASON GRADING OF CRIBRIFORM PATTERNS CRIBRIFORM PATTERN

• “rounded, well- • 3590 consecutive needle biopsies of PCa circumscribed glands of the reviewed for acceptable GG3 cribriform same size as normal glands” • 30 foci identified • “… most of cribriform patterns be diagnosed as 4 • Reviewed by 10 experts Gleason pattern 4 with only rare cribriform lesions • Only 1 case reached consensus (7/10) as a satisfying diagnostic criteria 33 “true” GG3 cribriform pattern for cribriform pattern 3” • For practical purposes GG3 cribriform Consensus opinion, 2005 pattern does not exist

Latour et al. Am J Surg Pathol 32:1532, 2008

GLEASON GRADING Gleason score 7 - not score 6 ISUP Consensus, 2005 AFIP Fascicle, 2012

All cribriform glands are grade 4 (ISUP 2015)

52 Complex Gleason grade 3 - not fused grade 4 Closely packed Gleason grade 3 - not fused grade 4

“Columns” of Gleason grade 3 - not nodule of grade 2 GLEASON GRADE 4

Raggedly infiltrating, poorly formed glands Fused glands - chains or solid masses Complex papillary-cribriform islands Hypernephroid and mucinous variants

GLEASON GRADE 4 GLEASON SCORE 7

53 Grade 4 – poorly formed glands Grade 4 – poorly formed glands

Fig. 6. Gleason score 4 + 3 = 7 adenocarcinoma, where pattern 4 component consists of discrete yet poorly formed glands.

Epstein JI et al. Am J Surg Pathol 29:1228, 2005

Grade 4 – poorly formed glands Grade 4 – poorly formed glands

Grade 4 – poorly formed glands Hypernephroid grade 4, not grade 5

54 Foamy grade 3 - not hypernephroid grade 4 GLEASON GRADE 5

Solid masses with no gland formation Infiltrating cords and single cells (including signet-ring cells) Comedonecrosis

GLEASON GRADE 5 GLEASON GRADE 5

GLEASON GRADE 5 Granular debris - not comedo necrosis grade 5

Gleason score 7 (4 + 3)

55 GLEASON SCORE 8 GLEASON SCORE 8 (5 + 3)

GLEASON SCORE 9 GLEASON SCORING

Collagenous micronodules – Glomerulations – considered subtract out the nodule and to be a grade 4 pattern grade accordingly (ISUP 2015)

GLEASON GRADING OF DUCTAL (ENDOMETRIOID) VARIANTS Ductal - endometrioid Grade 4, 5 with necrosis, rarely 3 Mucinous Grade 4 (rarely 3) Signet ring Grade 5 Sarcomatoid Grade 5 Pseudohyperplastic Grade 2 or 3, rarely 4 Xanthomatous (foamy) Grade 3 or 4 Atrophic Grade 3 or 2

From Amin, Grignon, Humphrey & Srigley, 2004

56 MUCINOUS CARCINOMA Grade 3 - not mucinous grade 4 Subtract out the mucin and grade accordingly

SIGNET RING-LIKE CARCINOMA INTRADUCTAL CARCINOMA • Included as distinct entity in 2016 WHO • Isolated IDC in NBx almost always (90%) associated with high grade carcinoma on RP • In >50% of cases there is EPE and/or SV invasion • IDC in the RP specimen is associated with a worse outcome (independent predictor) • Generally IDC is treated as high grade ca • ISUP 2015 recommends reporting IDC but not assigning a Gleason score to it

INTRADUCTAL CARCINOMA INTRADUCTAL CARCINOMA DIAGNOSTIC CRITERIA (WHO 2016) • Solid or dense cribriform pattern • Loose cribriform or micropapillary pattern with either: – Marked nuclear atypia (i.e. nuclear size 6x normal or larger) – Comedonecrosis

Comedonecrosis

57 INTRADUCTAL CARCINOMA INTRADUCTAL CARCINOMA

2015 ISUP/2016 WHO Revised Gleason Diagram

2015 ISUP/2016 WHO Revised Gleason Diagram RECOMMENDATIONS FOR THE REPORTING OF GLEASON GRADE • Report a Gleason score for all newly diagnosed prostate cancer Microcystic/cystic Pseudohyperplastic • Report the grades (patterns) with the glands glands score (sum) to make it clear what is Pseudo-atrophic present [eg Gleason score 7 (3 + 4)] glands Poorly formed glands • Reporting the % grade 4 is going to be Branching glands recommended in new 2015 ISUP/2016 WHO guidelines

Solid columns

58 SIGNIFICANCE OF % GRADE 4 RELEVANCE OF % GRADE 4/5

N=486 RP

PSA=10, 50 Gr, No IDC/SV

Choy et al. Am J Surg Pathol 2016 (in press)

Cole et al. J Urol 196:405, 2016

O’Brien et al, BJU Int 107:389-395, 2011

SIGNIFICANCE OF HIGH GRADE SIGNIFICANCE OF TERTIARY (<5%) HG TUMOR (4/5) GLEASON PATTERN (RP)

N=486 RP

Wise et al. Urology 60:264-269, 2002 Pan et al, Am J Surg Pathol 24:563, 2000

SIGNIFICANCE OF TERTIARY (<5%) HG GLEASON PATTERN (NBx): EBRT PROSTATE CANCER BX REPORT GLEASON SCORE N=312 “In needle biopsy specimens in which more than two patterns are present and the worst grade is neither the primary or secondary grade, the predominant and the highest grade should be chosen to arrive at a score (eg. 60% grade 3, 30% grade 4 and 10% grade 5 is scored 3 + 5 = 8).”

Srigley et al, Arch Pathol Lab Med 133:1568, 2009 ISUP Consensus, Am J Surg Pathol 29:1228, 2005 Nanda et al, Int J Rad Oncol Biol Phys 74:1419, 2009

59 TERTIARY GRADE

• 300 consecutive outside biopsies assigned a Gleason grade of 5 at JHH • In 146 (49%) grade 5 was not included in the outside Gleason scoring • Assigned grades on the outside were: • Gleason grades 4 (60%) > 3 • 3 + 3 = 6 3 ( 2%) (35%) > 5 (5%) • 3 + 4 = 7 27 (18%) • 4 + 3 = 7 31 (21%) • Report Gleason score as: • 4 + 4 = 8 85 (58%) 4 + 5 = 9 Urology 79:178-181, 2012

UNDER RECOGNITION OF GRADE 5 UNDER RECOGNITION OF GRADE 5

Assigned grade: 4 + 4 = 8 Assigned grade: 4 + 4 = 8 Assigned grade: 4 + 3 = 7 (there was grade 3 elsewhere)

PROSTATE CANCER BX REPORT PROSTATE CANCER BX REPORT GLEASON SCORE GLEASON SCORE

“In needle biopsy specimens where two patterns are present and the worst grade is neither the primary or secondary grade (eg. < 5% of volume) the predominant and the highest grade should be chosen to arrive at a score (eg. 98% grade 3, 2% grade 4 is scored 3 + 4 = 7)”

Srigley et al, Arch Pathol Lab Med 133:1568, 2009 ISUP Consensus, Am J Surg Pathol 29:1228, 2005

60 PROSTATE CANCER BX REPORT PROSTATE CANCER BX REPORT GLEASON SCORE GLEASON SCORE < 5% “In needle biopsy specimens where two 4 3 patterns are present and the lower grade is neither the primary or secondary grade GS 4 + 4 = 8 (eg. < 5% of volume) the lower grade < 5% should be ignored in arriving at a score 3 4 (eg. 96% grade 4, 4% grade 3 is scored 4 + 4 = 8)” GS 3 + 4 = 7

Srigley et al, Arch Pathol Lab Med 133:1568, 2009 ISUP Consensus, Am J Surg Pathol 29:1228, 2005

RECOMMENDATIONS FOR THE REPORTING OF GLEASON SCORES • Report a Gleason score for each positive biopsy when the biopsies are submitted as separate specimens • If needle biopsies from several sites are submitted in a single container, report the Gleason score for the specimen • In the situation where different cores are given different Gleason scores optional to J Urol 182:1364-1370, 2009 provide an overall Gleason score based on the total material received

Sextant biopsy submitted in 6 separate containers – Sextant biopsy submitted in 6 separate what is the Gleason score for treatment purposes? containers – what is the Gleason score?

L Apex 4+4=8 5% L Apex 4+4=8 5% L Mid 3+3=6 30% L Mid 3+3=6 30% L Base 3+3=6 60% L Base 3+3=6 60% R Apex 3+3=6 5% R Apex 3+3=6 5%

R Mid R Mid R Base R Base 80% of urologic oncologists surveyed would base treatment plan on GS 8 in this example Rubin et al, Am J Surg Pathol 28:946, 2004 Rubin et al, Am J Surg Pathol 28:946, 2004

61 Sextant biopsy submitted in 2 separate REPORT INDIVIDUAL CORES? containers – what is the Gleason score?

LA Left 3+4=7 30%

Right 3+3=6 <5%

80% of urologic oncologists surveyed would base treatment plan on GS 7 in this example Rubin et al, Am J Surg Pathol 28:946, 2004

GLEASON GRADING IN RP SPECIMENS GLEASON GRADING IN RP SPECIMENS • Gleason score is assigned using traditional primary + secondary with tertiary high grade noted if present • Gleason score is based on dominant nodule • If a second small nodule of higher grade is present this should also be reported • If no dominant nodule grade is assigned based on the peripheral zone tumor ignoring any low grade transition zone nodules

Epstein JI et al. Am J Surg Pathol, 2016 (in press) Arora et al. Cancer 100:2362-2366, 2004

IMPACT OF GLEASON SCORING IMPACT OF GLEASON SCORING CHANGES CHANGES • Classical Gleason score 3 + 3 =6 (622) • Decreased % of cases in GS ≤ 6 – Revised Gleason score: – Biopsy: 68% → 54% • 3 + 3 = 6 412 (66%) – RP: 47% → 32% • 3 + 4 = 7 199 (32%) • Zareba et al. Histopathology 55:384, 2009 • 4 + 3 = 7 9 • Improved concordance between BX & RP • 4 + 4 = 8 2 • Zareba et al. Histopathology 55:384, 2009 • Classical Gleason score 3 + 4 = 7 (184) • Uemura et al. BJU Int 103:1190, 2008 – Revised Gleason score: • Improved prognostic prediction • 3 + 4 = 7 136 (74%) • Uemura et al. BJU Int 103:1190, 2008 • 4 + 3 = 7 42 (23%) • Billis et al. J Urol 180:548, 2008 • 4 + 4 = 8 6 Dong et al. Am J Surg Pathol 36:8381, 2012

62 IMPACT OF GLEASON SCORING CHANGES

• 14,123 RP specimens with GS ≤ 6 and with LN dissection • 4 databases (JHH, Henry Ford, UCSF, Baylor) • All RP specimens had been completely embedded • 22 with + LNs (0.16%) • Slides available for review in 19 of 22 cases • ISUP Gleason score applied to the 19 cases • ALL cases upgraded on review

Am J Surg Pathol 36:1346-1352, 2012

Dong et al. Am J Surg Pathol 36:8381, 2012

“Use of the term ‘cancer’ should be reserved for describing lesions with a • Reasons for upgrading (19 cases): reasonable likelihood of lethal • Cribriform glands: 17 cases progression if left untreated” • Poorly formed glands: 3 cases • Mucinous variant: 1 case • Ductal variant: 1 case JAMA August 28, 2013 • “it can now be concluded that GS ≤ 6 using the updated system lacks the potential to metastasize to

regional LN’s” Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease. National Research Am J Surg Pathol 36:1346, 2012 Council

GLEASON GRADE GROUPING

GROUPING REFERENCES 2-6 vs 7-10 Epstein (1993); Hanks (1995) 2-5 vs 6-7 vs 8-10 Pilepich (1987) 2-4 vs 5-7 vs 8-10 Russel (1991), Catalona (1994) 2-4 vs 5-6 vs 7-10 Freedland (2000) 2-6 vs 7 vs 8-10 DAmico (1998); Tefilli (1999) “Let us make the case and put in the effort to develop improved prostate cancer screening for the higher grade prostate , while at the 2-5 vs 6 vs 7 vs 8-10 Bagshaw (1990) same time relegating low volume Gleason 6 to the status of no more 2-3 vs 4-6 vs 7 vs 8-10 Zagars (1995) than a significant risk factor. Let us decide as a profession to stop the 2-4 vs 5-6 vs 7 vs 8-10 Ohori (1994); Epstein (1996) push for inappropriate, expensive, inopportune and perhaps even unethical radical therapies for a condition that by itself does not kill our 2-4 vs 5 vs 6 vs 7 vs 8-10 Partin (1997) patients.” 2-3 vs 4-5 vs 6 vs 7-8 vs 9-10 Gleason (1977) 2-6 vs 3+4 vs 4+3 vs 8-10 Makarov/Partin (2007) Nickel JC & Speakman M. BJU Int 109:645, 2012 2-6 vs 3+4 vs 4+3 vs 8 vs 9-10 Eifler/Partin (2013)

Modified from Humphrey PA. Prostate Pathology, ASCP Press, 2003

63 GLEASON GRADE GROUPING GLEASON GRADE GROUPING

Pierorazio et al. BJU Int 111:753-760, 2013 Pierorazio et al. BJU Int 111:753-760, 2013

GLEASON GRADE GROUPING GLEASON GRADE GROUPING

GLEASON ISUP GRADE GROUP SCORE 6 or less 1 7 (3 + 4) 2 7 (4 + 3) 3 8 4 9 - 10 5

Worst needle biopsy score Overall needle biopsy score ISUP (2015), WHO (2016) & CAP (In press) recommend the reporting of the Grade Group in addition to the Gleason Score (Biopsy & RP) Berney DM, et al. Br J Cancer 114:1078, 2016

PCA NEEDLE BX REPORT VOLUME OF CANCER IN THE CAP RECOMMENDATIONS (2012) NEEDLE BIOPSY • Histologic type • Univariate predictors of PSA failure after • Gleason score (include 1º and 2º [worst]) radical prostatectomy: • Quantitation of tumor (as # of cores and % tissue or mm of tumor) – % positive cores 0.0075 • Local invasion (document if identified) – Greatest % cancer 0.06 – peri-prostatic fat – Total % cancer 0.00086 – seminal vesicle – Total mm cancer 0.0028 • Perineural invasion* – Greatest mm cancer 0.01 • Blood/lymphatic vessel invasion* – High grade mm cancer 0.0000097 • Other pathologic findings* Srigley et al, CAP web site June 2012 revision Brimo et al, Histopathol 53:177, 2008

64 COUNTING CORES What is the % surface area involvement?

P=0.002

Tumor

Tumor

What is the % surface area involvement? CAP/ISUP/ADASP Recommendation “involving 1 of 6 cores with 2 discontinuous foci measuring 4 mm in aggregate, involving 15% of the core and spanning 80% of the core” Tumor Tumor

Tumor Tumor Amin MB, et al. Arch Pathol Lab Med 138:1387, 2014

VOLUME OF CANCER IN THE ACTIVE SURVEILLANCE IN NEEDLE BIOPSY PROSTATE CANCER: ELIGIBILITY • Discontinuous defined as > 2 mm between cancer foci (10x field) • Median gap was 3.5 mm • 40 Bx-RP pairs (out of approximately 2400 RP cases) INSTITUTION GLEASON # POSITIVE % CORE SCORE CORES POSITIVE Hopkins ≤ 6 ≤ 2 ≤ 50% MSKCC ≤ 6 ≤ 3 ≤ 50% 78% 22% Schroder ≤ 6 ≤ 2 -- UCSF ≤ 6 ≤ 33% (min 6) ≤ 50% U Miami ≤ 6 ≤ 2 ≤ 20% Canary trial ≤ 7 (3 + 4) ≤ 33% -- UK trial ≤ 6 or ≤ 50% -- ≤ 7 (3 + 4) if > 65

Arias-Stella et al. Am J Surg Pathol 39:281-286, 2015

65 PCA - STAGING WITH BIOPSIES SEMINAL VESICLE BIOPSY

Positive seminal vesicle biopsy – at least pT3b

SEMINAL VESICLE BIOPSY PERINEURAL INVASION Negative seminal vesicle biopsy

Peripheral Zone Cancer - Pattern of Spread

PERINEURAL INVASION LYMPH-VASCULAR INVASION

BJU Int 114:75-80, 2014

J Urol 194:1258-1263, 2015

“The existing literature is conflicting and of insufficient homogeneity to definitively establish LVI as an important independent prognostic factor of biochemical recurrence in prostate cancer radical prostatectomy specimens” BJU Int 110:1507, 2012

66 67 REPORTING OF CANCER IN NEEDLE BIOPSY SPECIMENS: GLEASON GRADING AND MORE - SELECTED REFERENCES (2016)

Moch H, Reuter V, Humphrey P, Ulbright T. World Health Organization Histologic and Genetic Typing of Tumours of the Kidney, Urinary Bladder, Prostate Gland and Testis. Lyon, France: IARC Press; 2016.

Epstein JI, Cubilla AL, Humphrey PA. Tumors of the Prostate Gland, Seminal Vesicles, Penis and Scrotum. AFIP Fascicle, Series 4. American Registry of Pathology, Washington, DC, 2011.

Amin M, Grignon D, Humphrey P, Srigley J. Gleason Grading: A Contemporary Approach. Philadelphia, PA: Lippincott, Williams & Wilkins; 2004.

Epstein JI, Allsbrook WC, Jr., Amin MB, Egevad LL, Committee IG. The 2005 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma. Am J Surg Pathol 2005;29:1228-42.

Faraj SF, et al. Clinical validation of the 2005 ISUP Gleason grading system in a cohort of intermediate and high risk men undergoing radical prostatectomy. PLoS One 2016 5;11:e0146189

Berg KD, et al. The impact of the 2005 International Society of Urological Pathology consensus guidelines on Gleason grading - a matched-pair analysis. BJU Int 2016;117:883-9.

Giunchi F, et al. Revised Gleason grading system is a better predictor of indolent prostate cancer at the time of diagnosis: retrospective clinical-pathological study on matched biopsy and radical prostatectomy specimens. Clin Genitourin Cancer 2014;12:325-9.

Zareba P, Zhang J, Yilmaz A, Trpkov K. The impact of the 2005 International Society of Urological Pathology (ISUP) consensus on Gleason grading in contemporary practice. Histopathology 2009;55:384-91.

Vis A, Roemeling S, Kranse R, et al. Should we replace the Gleason score with the amount of high-grade prostate cancer? Eur Urol 2007;51:931-9.

Pan CC, Potter SR, Partin AW, Epstein JI. The prognostic significance of tertiary Gleason patterns of higher grade in radical prostatectomy specimens: a proposal to modify the Gleason grading system. Am J Surg Pathol 2000;24:563-9.

Patel AA, Chen M-H, Renshaw AA, D'Amico AV. PSA failure following definitive treatment of prostate cancer having biopsy Gleason score 7 with tertiary grade 5. JAMA 2007;298:1533-8.

68 Nanda A, Chen M-H, Renshaw AA, D'Amico AV. Gleason Pattern 5 prostate cancer: further stratification of patients with high-risk disease and implications for future randomized trials. Int J Rad Oncol Biol Phys 2009;74:1419-23.

Billis A, Guimaraes MS, Freitas LLL, et al. The impact of the 2005 International Society of Urological Pathology consensus conference on standard Gleason grading of prostatic carcinoma in needle biopsies. J Urol 2008;180:548-52.

Uemura H, Hoshino K, Sasaki T et al. Usefulness of the 2005 International Society of Urologic Pathology Gleason grading system in prostate biopsy and radical prostatectomy specimens. BJU Int 2009;103:1190-4.

Dong F, Wang C, Farris AB, et al. Impact on the clincal outcome of prostate cancer by the 2005 International Society of Urologic Pathology modified Gleason grading system. Am J Surg Pathol 2012;36:838-843.

Kweldam CF, Wildhagen MF, Steyerberg EW, et al.Cribriform growth is highly predictive for postoperative metastasis and disease-specific death in Gleason score 7 prostate cancer. Mod Pathol 2015;28:457-64.

Epstein JI, Egevad L, Amin MB, Delahunt B, Srigley JR, Humphrey PA; ISUP Grading Committee. The 2014 International Society of Urological Pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma: definition of grading patterns and proposal for a new grading system. Am J Surg Pathol 2016;40:244-52.

Eifler JB, et al. An updated prostate nomogram (Partin tables) based on cases from 2006 to 2011. BJU Int 2013;111:22-9.

Pierorazio PM, Walsh PC, Partin AW, Epstein JI. Prognostic Gleason grade grouping: data based on the modified Gleason scoring system. BJU Int 2013;111:753-60.

Egevad L, Delahunt B, Srigley JR, Samaratunga H. International Society of Urological Pathology (ISUP) grading of prostate cancer - An ISUP consensus on contemporary grading. APMIS 2016;124:433-5.

Delahunt B, et al. Validation of International Society of Urological Pathology (ISUP) grading for prostatic adenocarcinoma in thin core biopsies using TROG 03.04 'RADAR' trial clinical data. Pathology 2015;47:520-5.

Samaratunga H, et al. The prognostic significance of the 2014 International Society of Urological Pathology (ISUP) grading system for prostate cancer. Pathology 2015;47:515- 9.

Spratt DE, et al. Independent validation of the prognostic capacity of the ISUP prostate cancer grade grouping system for radiation treated patients with long-term follow-up. Prostate Cancer Prostatic Dis. 2016 May 24 [Epub ahead of print]

69 Berney DM, Beltran L, Fisher G, et al. Validation of a contemporary prostate cancer grading system using prostate cancer death as outcome. Br J Cancer 2016;114:1078- 1083.

Harding-Jackson N, et al. Outcome of Gleason 3+5=8 prostate cancer diagnosed on needle biopsy: prognostic comparison with Gleason 4+4=8. J Urol 2016 Jun 2 [Epub ahead of print]

van den Bergh RC, et al. Validation of the novel ISUP-2014 5-tier Gleason grade grouping: Biochemical recurrence rates of 3+5 disease may be overestimated. BJU Int 2016 Mar 12 [Epub ahead of print]

Huang CC, Kong MX, Zhou M, et al. Gleason Score 3 + 4=7 Prostate cancer with minimal quantity of Gleason pattern 4 on needle biopsy is associated with low-risk tumor in radical prostatectomy specimen. Am J Surg Pathol 2014;38:1096-101.

Cole AI, Morgan TM, Spratt DE, et al. Prognostic value of percent Gleason grade 4 at prostate biopsy in prediciting prostatectomy pathology and recurrence. J Urol 2016;196:405-411.

Choy B, Pearce SM, Anderson BB, et al. Prognostic significance of percentage and architectural types of contemporary Gleason pattern 4 prostate cancer in radical prostatectomy. Am J Surg Pathol 2016 (in press)

Iremashvili V, Burdick-Will J, Soloway MS. Improving risk stratification in patients with prostate cancer managed by active surveillance: a nomogram predicting the risk of biopsy progression. BJU Int 2013; 112:39-44.

Latour M, Amin MB, Billis A et al. Grading of invasive cribriform carcinoma on prostate needle biopsy: an interobserver study among experts in genitourinary pathology. Am J Surg Pathol 2008;32:1532-9.

Gottipati S, Warncke J, Vollmer R, Humphrey PA. Usual and unusual histologic patterns of high Gleason score 8 to 10 adenocarcinoma of the prostate ijn needle biopsy tissue. Am J Surg Pathol 2012;36:900-907.

Ross HM, Kryvenko ON, Cowan JE, et al. Do adenocarcinomas of the prostate with Gleason score (GS) ≤6 have the potential to metastasize to lymph nodes? Am J Surg Pathol 2012;36:1346-1352.

Carter HB, Partin AW, Walsh PC, et al. Gleason score 6 adenocarcinoma: should it be labeled as cancer? J Clin Oncol 30:4294-6, 2012.

Brimo F1, Montironi R, Egevad L, et al. Contemporary grading for prostate cancer: implications for patient care. Eur Urol 2013;63:892-901.

70 Nickel JC, Speakman M. Should we really consider Gleason 6 prostate cancer? BJU Int 2012;109:645-6.

D'Amico AV, Renshaw AA, Cote K et al. Impact of the percentage of positive prostate cores on prostate cancer-specific mortality for patients with low or favorable intermediate-risk disease. J Clin Oncol 2004;22:3726-32.

Vira MA, Tomaszewski JE, Hwang W-T et al. Impact of the percentage of positive biopsy cores on the further stratification of primary grade 3 and grade 4 Gleason score 7 tumors in radical prostatectomy patients. Urology. 2005;66:1015-9.

Newcomb LF, et al. Outcomes of active surveillance for clinically localized prostate cancer in the prospective, multi-institutional Canary PASS cohort. J Urol 2016;195:313- 20.

Antonelli A, Vismara Fugini A, Tardanico R, et al. The percentage of core involved by cancer is the best predictor of insignificant prostate cancer, according to an updated definition (tumor volume up to 2.5 cm): analysis of a cohort of 210 consecutive patients with low-risk disease. Urology 2014;83:28-32.

Chen DJ, et al. Does cumulative prostate cancer length (CCL) in prostate biopsies improve prediction of clinically insignificant cancer at radical prostatectomy in patients eligible for active surveillance? BJU Int 2015;116:220-9.

Kajikawa K, et al. Optimal method for measuring tumor extent in needle biopsy specimens to identify small-volume prostate cancer. Int J Urol 2016;23:62-8.

Harnden P, Shelley MD, Clements H et al. The prognostic significance of perineural invasion in prostatic cancer biopsies: a systematic review. Cancer. 2007;109:13-24.

Yang R, et al. Perineural invasion status, Gleason score and number of positive cores in biopsy pathology are predictors of positive surgical margin following laparoscopic radical prostatectomy. Asian J Androl 2016 Mar 18 [Epub ahead of print]

Cohn JA, Dangle PP, Wang CE, et al. The prognostic significance of perineural invasion and race in men considering active surveillance. BJU Int 2014;114:75-80.

Moreira DM, Fleshner NE, Freedland SJ. Base line perineural invasion is associated with shorter time to progression in men with prostate cancer undergoing active surveillance: results from the REDEEM study. J Urol 2015;194:1258-1263.

Fleshner K, et al. Clinical findings and treatment outcomes in patients with extraprostatic extension identified on prostate biopsy. J Urol 2016 Apr 2 [Epub ahead of print].

71 72 73 74  No conflict of interest

UNRAVELING THE MESENCHYMAL MADNESS IN GYNECOLOGIC TUMORS

Kristen Atkins, MD University of Virginia October 2016

 A 36 year-old woman presents with a polypoid cervical mass. Small biopsies are taken.

SMOOTH MUSCLE DIFFERENTIATION WHAT IS YOUR DIAGNOSIS?

 with atypia  Smooth muscle tumor of uncertain malignant potential  Leiomyosarcoma  Gestational trophoblastic tumor

75 Tumor cell necrosis TYPES OF NECROSIS, ARTIFACTS

Cytologic Atypia

Mitoses

DISTINGUISHING CTCN FROM INFARCT Tumor cell necrosis NECROSIS

Tumor necrosis Benign Necrosis

 Multifocal  Single  Irregular borders  Smooth borders  Sharp interface btwn  Sclerotic edge dead and viable  Interface  Little inflammation inflammation

Adapted from Cpt 20 Diagnostic Gynecolgic and Obstetric Pathology

NOT ALL CYTOLOGIC ATYPIA IS BAD BENIGN ATYPIA

Atypia in a leiomyosarcoma

76 ATYPICAL LEIOMYOMA (SYMPLASTIC LEIOMYOMA, LEIOMYOMA WITH BIZARRE CELLS)

ATYPICAL

 If negligible mitoses and no necrosis, they behave in a benign fashion  In largest series all had fewer than 4 mitoses/10 hpf  Be careful when:  Mitoses approach 10/10  Infiltrative borders

 This is the time to sample more.

Ly A, et al Atypical leiomyomas of the uterus: a clinicopathologic study of 51 cases. AJSP 2013; 37(5): 643-9

MYXOID SMOOTH MUSCLE TUMORS

 Initial reports scary  Can use same features as usual SMTs, but lower cut off points  Warning flags: irregular borders, necrosis

King et al Myxoid leiomyosarcoma of the uterus. A report of six cases. AJSP 1982; 6(7):589-98.

77 HYDROPIC DEGENERATION

78 EPITHELIOID VARIANTS OF SMTS

 Canuse the same variables as usual SMTS but lower the threshold  Think about PEComa

79 Smooth muscle actin HMB45 SO, WHAT IS STUMP?

 Necrosis challenging to classify  Boderline cut-off cases (all subtypes)  Inadequate sampling

2014 WHO CLASSIFICATION OF ENDOMETRIAL STROMAL TUMORS ENDOMETRIAL STROMAL SARCOMA

 Endometrial stromal nodule  Low-grade endometrial stromal sarcoma  High-grade endometrial stromal sarcoma  Undifferentiated uterine sarcoma

 JAZF1-SUZ12 gene fusion in 50% usual ESS  CD10 positive, ER positive  SMA patchy positive

 Vimentin, keratin patchy, SMA, desmin patchy, some B-catenin and WT-1

80 HIGH GRADE ESS

 Often lack CD10, ER, and PR  Consistently have a t(10;17)  Cyclin D1 positive

Oliva E Cellular mesenchymal tumors of the uterus: a review emphasizing recent observations. Int J Gyn Pathol 2014; 33(4): 374-84

p53

Cyclin D1

81 ESS WITH SEX CORD-LIKE ELEMENTS

 60% ESS  Resemble granulosa cells or sertoli cells

ESS WITH MINOR SEX CORD DIFFERENTIATIONS VS UTERINE TUMORS RESEMBLING OVARIAN SEX CORD TUMORS

 If any stromal sarcoma component it is classified as an ESS.

MOST IMPORTANT DIFFERENTIAL DIAGNOSES ARE STROMAL NODULE AND CELLULAR LEIOMYOMA ENDOMETRIAL STROMAL NODULE

 ESS and ESN pre- and perimenopausal aged women  Noninfiltrative margins (sort of)

82 ESN AND MARGINS, LVI

 <3 finger-like projections or satellite nodules each <3 mm are allowed for ESN  No LVI allowed  Mitotic activity not helpful

Oliva E Cellular Mesenchymal Tumors od the Uterus: a review emphasizing recent observations Int J Gyn Pathol 2014;33: 374-384.

 A 40-year-old woman presents with a polyp protruding through the cervix. It is unclear if it is coming down from the uterus or endocervix. Imaging shows enlargement of the uterine corpus. Biopsies are taken twice.

83 BIOPSIES SET #1

BIOPSIES SET #2

DISCUSSION WITH THE CLINICIAN

 “This mass is compressing the bowel and the IVC. She’s delayed treatment form over a year and so I don’t think this is an aggressive process. BUT it is definitely growing.

84 DIAGNOSTIC AIDS?

 Ki67 highlights cuffing  20% near epithelium  Not seen in endometrial polyps or atypical adenomatoid polyps

Aggarwal N et al Uterine adenosarcomas: diagnostic use of the proliferation marker Ki67as an adjunct to morphologic diagnosis Int J Gyn Pathol 2012; 31(5): 447-52

85 THANK YOU [email protected]

86 87 88 REGISTER TODAY!

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