A Practical Approach to Surgical and Cytopathology

3rd Annual A Practical Approach to Surgical and Cytopathology

Friday, April 7, 2017

Hotel Del Coronado Coronado, California

Educational Symposia TABLE OF CONTENTS

Friday, April 7, 2017

Diagnostic Approach to Flat and Papillary Urothelial Lesion (Ming Zhou, M.D.)...... 137

Practical Issues Related to the Endometrium Biopsy II (Marisa Rose Nucci, M.D.)...... 155

What’s New in the World Health Organization Classification of Lung Tumors (Carol Farver, M.D.)...... 185

Thyroid Pathology in the Molecular Era (Jennifer L. Hunt, M.D.)...... 199

Pattern Based Approach to Diagnosis and Classification of Renal Tumors (Ming Zhou, M.D.)...... 215

SAVE THE DATES - 2018 Pathology Symposia 137 138 Diagnostic Approach to

Papillary and Flat Urothelial Clinical Implications of Pathological Diagnoses on TUR or Biopsy Specimens: Lesions What Diagnoses Pathologists Really Matter? Ming Zhou, MD, PhD Dr. Charles T. Ashworth Professor of Pathology Director, Anatomic Pathology The University of Texas Southwestern Medical Center Dallas, TX [email protected] What Diagnoses Pathologists May Not Need to Struggle with?

Pathological Parameters Important Urothelial Carcinoma Staging for Management of Patients with Ta, Tis- non- Urothelial Carcinoma invasive T1- Lamina propria invasion 1. Depth of invasion )tumor stage) T2- muscularis 2. Tumor grade propria invasion 3. Variant histology T3- Perivesical 4. Lymphovascular invasion invasion T4- Invasion into adjacent organs

AJCC 2016 3 4

Grading of Papillary Urothelial Clinical Decision Based on Stage and Grade

Neoplasms Muscle Radical cystectomy WHO 2016 Invasive UC LN dissection Biopsy/TUR Non-muscle 1. Papilloma Invasive UC 2. Papillary urothelial neoplasm of low malignant potential (PUNLMP) Low risk Intermediate risk High risk 3. Low grade papillary urothelial carcinoma (initial, single, low (recurrent, multifocal (High grade) 4. High grade papillary urothelial carcinoma grade, <3cm) low grade, >3cm)

Single installation Multiple installation of of intravesical intravesical chemo BCG chemo

5 (European Society of Medical Oncology) 6

139 Urothelial Carcinoma Variant Histology Clinical Decision Based on Stage and Grade Squamous cell Glandular What is critical? - Invasion of muscularis propria - High grade UC

What is not so critical? - Invasion of lamina propria vs Nested Micropapillary non-invasive - Low grade vs PUNLMP

7 8

Urothelial Carcinoma Variant Histology Urothelial Carcinoma Variant Histology Significance What to do? 1. Common, seen in up to ¼ cases - Squamous histology most common 1. Report any component of variant 2. In general, no impact on clinical histology outcomes 2. Diagnosis of “pure variant histology” 3. Associated with aggressive pathological reserved for cases without concomitant features urothelial carcinoma and CIS component - Invasion of muscularis propria 3. Otherwise, diagnose “urothelial - Lymph node metastasis carcinoma with a component of variant - Upstaging histology” 4. Rule out metastasis 9 10

Lymphovascular Invasion (LVI) Diagnostic Criteria for LVI LVI Retraction Significance of LVI - Predicts worse clinical outcomes - LVI in TUR associated with higher risk for upstaging in radical

cystectomy (Turker et al BJUI 2012) 30% T<1 TCC with LVI in TUR was Clear endothelial lining No upstaged in radical cystectomy Single/a few Multiple Odds ratio=5.8 Tight cluster with smooth border Rough borders with single cells Fibrin, RBC Cellular debris

11 (Algaba Current Opinion Urol 2006) 12

140 Clinical Implications of Pathological Lymphovascular Invasion in TUR Diagnoses on TUR or Biopsy Specimens: Take home message

What to do? Top 4 Diagnoses in TUR/Biopsy Specimens 1. Look for and report it 1. Invasion of muscularis propria 2. Use stringent criteria 2. High grade urothelial carcinoma - Minimum criterion: true endothelial lining 3. Endothelial markers in ambiguous cases 3. Variant histology 4. Lymphovascular invasion

13 14

Case 1

1. 58-year-old paraplegic female 2. Gross hematuria 3. 1.3-cm papillary lesion on cystoscopy

141 Differential Diagnosis of Papillary Your Diagnosis? Lesions of the Bladder Biopsy artifact Polypoid mucosal folds Inflammatory lesions 1. Urothelial papilloma Proliferative cystitis Polypoid cystitis 2. Low grade papillary urothelial carcinoma Nephrogenic adenoma 3. High grade papillary urothelial carcinoma Papillary urothelial hyperplasia Papillary urothelial neoplasms 4. Papillary nephrogenic adenoma Papilloma Papillary neoplasm of low malignant potential Low grade carcinoma NOT ALL High grade PAPILLARY carcinoma LESIONS ARE Non-urothelialPAPILLARY neoplasms UROTHELIAL Condyloma Villous adenomaCARCINOMA!

19 20

Differential Diagnosis of Papillary Urothelial Lesions Detached Papillary Structures of the Urinary Bladder

Are detached papillary structures present?

No Yes Morphology of the papillary structures

Mucosal folds Papillary hyperplasia Broad Thin Edematous Slender Inflammatory lesion Inflamed Non-inflamed Biopsy artifact

Polypoid cystitis Papillary urothelial Inflammatory neoplasm lesion

Papillary Urothelial Hyperplasia (Urothelial proliferation of uncertain malignant potential, WHO 2016)

Undulating mucosal folds without detached papillary fronds Thicker than normal urothelium; increased vascularity at base

142 Papillary Urothelial Hyperplasia Papillary Urothelial Hyperplasia (Urothelial proliferation of uncertain malignant potential, WHO 2016)

De novo diagnosis Significance unknown; suggest clinical follow-up Prior h/o papillary tumors Early recurrence Patient monitored more closely than the general population

Cytology similar to normal urothelium 26

Differential Diagnosis of Papillary Urothelial Lesions of the Urinary Bladder Neoplastic Reactive Papillae Papillae Are detached papillary structures present?

No Yes Morphology of the papillae

Mucosal folds Papillary hyperplasia Broad Thin Edematous Slender Inflammatory lesion Inflamed Non-inflamed Biopsy artifact

Inflammatory lesion Papillary urothelial Polypoid cystitis neoplasm

27 28

Fat Neoplastic Papillae

Usually a focal finding Case 1: Reactive (papillary nephrogenic adenoma) Thin papillae always neoplastic

143 Correlation of Cystoscopic Impression with Histologic Diagnosis of Biopsy Specimens WHO/International Society of Urological Pathology Classification of Papillary of the Bladder Urothelial Neoplasms (WHO 2016) Cystoscopy correctly discriminates between dysplastic/malignant and benign/reactive 1. Papilloma lesions 2. Papillary neoplasm of low malignant - Sensitivity and specificity: 100% potential (PUNLMP) - Positive and negative predictive value: 100% 3. Papillary carcinoma, low grade When you are not sure if you are looking at a 4. Papillary carcinoma, high grade papillary tumor or reactive lesion, talk to your urologists!

Cina et al Hum Pathol 2001 31 32

Grading of Papillary Urothelial Neoplasm Grading of Papillary Urothelial Neoplasms

Papilloma PUNLMP Low grade High grade

Architecture of Delicate Delicate Fused / branched / delicate 1. Architecture of papillae papillae occasionally fused 2. # of cell layers # of cell layers Normal Any thickness Organization of 3. Disorganization of cells Normal Normal Loss of polarity 4. Nuclear size cells 5. Nuclear shape Nuclear size Normal Slightly 6. Chromatin Nuclear shape Normal Uniform Variation in size and shape 7. Nucleoli Chromatin Fine Fine Hyperchromasia 8. Mitosis Nucleoli Absent Prominent Rare Occasional any Frequent Mitosis Absent basal level any level

33 34

Simplified Approach for Grading Papillary Papilloma Urothelial Tumors

Normal urothelium Papilloma on a simple stalk Thick, normal appearing urothelium PUNLMP on a stalk Abnormal urothelium w/ uniformity Low grade Simple papillae covered with on a stalk normal urothelium

Abnormal urothelium Not papilloma if: w/o uniformity High grade - Thickened urothelium on a stalk - Fused or branching papillae 35 36

144 PUNLMP Low grade

Normal, but thicker mucosa

Not PUNLMP if: Appreciable atypia at low power, - Appreciable atypia at low power but uniformity maintained

High grade Grading Papillary Urothelial Tumors: Issues 1. Grading represents arbitrary division of a morphological continuum into distinct categories that correlate with clinical behavior - Borderline cases exist 2. More objective parameters are not used in the grading scheme - Mitosis - Immunohistochemistry Uniformity lost (size, shape, spacing) 40

Grading Papillary Urothelial Tumors: FAQ

1. Do you use mitosis to grade? - No - Yes in selective cases (borderline b/w low and high grade) - State the reason in Comment:

This tumor is histologically low grade, but has brisk mitosis. Therefore it is graded as high grade.

145 Grading Papillary Urothelial Tumors: FAQ Grading Papillary Urothelial Tumors: FAQ

2. Do you use IHC to grade? 3. How do you sign out a low grade tumor with - No focal high grade component? - Too much overlap between tumors of - 5% cutoff (but no hard data on this!) different grades - < 5%: Low grade with focal high grade component - Urologists treat patient like high grade - > 5%: High grade

43 44

Denuded Papillae Denuded Papillae

What happened?

1. Majority of cases (79%) associated with high grade 2. Caused by biopsy artifact - 52% with cautery artifact - 48% due to mechanical disruption in anatomically limited areas (ureter, renal pelvis, urethra)

Owens et al AJSP 2007

Denuded Papillae Denuded Papillae

What to do?

1. Prompt careful examination of the specimen for rare clinging high-grade carcinoma cells 2. Correlate with concurrent urine cytology specimens Dx: Denuded papillae, consistent with HGTCC with denudation

146 Diagnosis of Papillary Urothelial Lesions Case 2 Take home message 1. All papillary lesions are not neoplastic 2. Use the morphology of fibrovascular cores to 72 y.o. man with history of cigarette distinguish neoplastic and reactive papillary smoking lesions New onset of hematuria - Thin: tumor - Thick: reactive Cystoscopy: irregular hyperremic 3. Grading of papillary tumors made easy mucosa in the bladder dome - Normal urothelium on a simple stalk: papilloma - Normal but thick urotheliu on a stalk: PUNLMP - Atypical urothelium with uniformity: low grade - Atypical urothelium without uniformity: high grade

49 50

51 52

Flat Urothelial Lesions Your Diagnosis (Without papillary structures) WHO/ISUP Classiﬁcation of Flat Intraurothelial Lesions Benign denuded urothelium Benign urothelium with reactive atypia 1. Normal urothelium Low grade urothelial dysplasia 2. Flat urothelial hyperplasia Urothelial carcinoma in situ, clinging 3. Flat lesions with atypia cell type - Reactive atypia - Dysplasia (low grade dysplasia) - High grade dysplasia/CIS - Atypia of unknown signiﬁcance

53 54

147 Normal Urothelium

Umbrella cells

4-6 Intermediate cells layers

Basal cells

Normal urothelial cells Uniformity: the key to the diagnosis of = 2X stromal lymphocytes normal urothelium! “Rule of stromal lymphocytes!” 3 S’(Size, Shape, Spatial arrangement) 55 56

Umbrella Cells in Normal Urothelium Flat Urothelial Hyperplasia

May exhibit signiﬁcant atypia Ignore atypia in surface urothelium when evaluating for dysplasia/CIS Markedly thickened mucosa without cytological atypia

Umbrella cells may be present in dysplasia and CIS 57 Speciﬁc # of cell layers: not required 58

Flat Urothelial Hyperplasia Flat Urothelial Lesions with Atypia (Urothelial proliferation of uncertain 3-Step Diagnostic Approach malignant potential, WHO 2016) Size Shape Architectural features Spatial arrangement 1 Uniformity Spacing (Low magniﬁcation) Parallel to each other May be seen adjacent to low grade Perpendicular to urothelial carcinoma basement membrane)

Isolated flat hyperplasia- no data to Nuclear size (compare with stromal suggest premalignant potential Cytological features lymphocytes) 2 (High magnification) Membrane Chromatin Nuclear attributes Nucleoli Mitosis Rule out conditions Inflammation 3 that may cause atypia Intravesical treatment Radiation 59 60

148 Nuclear size (compare with stromal Size Cytological features lymphocytes) Shape (High magniﬁcation) Architectural features Spatial arrangement 2 1 (Low magniﬁcation) Uniformity Spacing Parallel to each other “Rule of stromal lymphocyte” Perpendicular to (Milford R et al Hum Pathol 2001) basement membrane) Normal: 2X Dysplasia: 3-4X CIS: 4-5X Normal Abnormal

61 62

Cytological features Membrane Rule out conditions Inﬂammation 2 (High magniﬁcation) Chromatin Nuclear attributes 3 that may cause atypia Intravesical treatment Nucleoli Radiation Mitosis

Reactive atypia due to inﬂammation Degenerative atypia due to radiation

Normal CIS 63 64

Working up Flat Urothelial Lesions Working up Flat Urothelial Lesions Immunohistochemistry Immunohistochemistry H&E CK20 CD44 p53 Indications 1. Reactive atypia vs CIS - Atypia of unknown signiﬁcance Benign 2. Conﬁrm the diagnosis of CIS with unusual morphology

Reactive Caveats 1. Diagnosis based primarily on H&E morphology; IHC supportive CIS 2. Not for distinguishing dysplasia and CIS McKenney J et al AJSP 2001 65 66

149 Reactive Atypia Urothelial Carcinoma in Situ (CIS)

Uniformity maintained (size, shape, spacing); polarity may be lost Nuclei uniformly enlarged, smooth nuclear membrane and chromatin, Unequivocal loss of uniformity (size, shape, spacing); polarity may be lost prominent nucleoli Unequivocal nuclear atypia (nuclei enlarged 4-5X, irregular nuclear membrane, In ﬂammation in the mucosa or lamina propria coarse chromatin, prominent nucleoli, mitosis at upper level)

History of stone, trauma, cystitis, therapy In ﬂammation may be present, but not enough to account for atypia 68

Urothelial Carcinoma in Situ Urothelial Carcinoma in Situ Clinging cell type Pagetoid spread

Urothelial Carcinoma in Situ Involving von Brunn nests Flat Urothelial Lesions: A Morphological Continuum

Severe Mild to moderate Degree of atypia Degree None

Benign Dysplasia CIS

71 72

150 Urothelial Dysplasia Diagnostic Criteria for Urothelial Dysplasia

1. Unequivocal neoplastic atypia - Not enough for CIS

2. Diagnostic criteria subjective - The only objective criterion: 3-4 X stromal lymphocytes (“rule of lymphocytes”!) in dysplasia > 5 x stromal lymphocytes in CIS Uniformity: slight loss (variation in size; irregular spacing) Nuclei: enlarged (3-4X), hyperchromasia, increased mitosis In ﬂammation: absent

73 74

Urothelial Atypia with Unknown Signiﬁcance (Diagnostic category, not an entity!) Intravesical Chemotherapy with Thiotepa and Mitomycin C

1. Applied intravesically for non-muscle invasive TCC 2. Alkylating agents cross-linking biomolecules 3. Also act as topical abrasive agent to destroy tumor 4. Histological changes - Necroinﬂammation of urothelium - Atypical changes in surface urothelium Umbrella cells become large, vacuolated and multinucleated 76 Frank atypia + brisk inﬂammation 75

Urothelial Changes after Intravesical Chemotherapy Denudation of surface urothelium Urothelial Changes after Intravesical Chemotherapy Atypical changes in the umbrella cells Vascular ectasia, hemorrhage and edema in lamina propria 77

151 Urothelial Atypia with Unknown Signiﬁcance Working up Flat Urothelial Lesions

Low power High power 1. Flat lesion with significant atypia AND Uniformity Nuclear size Background significant inflammation (size, shape, spacing) + Nuclear attributes + Inflammation 2. Diagnostic category, not a biological entity Polarity - Reactive lesion with significant architectural and cytological atypia - Dysplasia or CIS associated with significant inflammation Uniformity + Uniformity - Nuclear enlarged Frank atypia 3. Implication for urologists: treat inflammation Nuclear atypia Significant inflammation Prominent nucleoli No significant inflammation and follow up with repeat biopsy Significant inflammation 4. Do not abuse it: not for “a diagnosis that I am not sure about or have no clue for” Reactive Dysplasia Atypia of atypia CIS unknown significance 79 80

Questions?

[email protected]

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196 197 198 199 200 Dissecting “Indeterminants”

Thyroid nodule management “Indeterminants”: Benign vs. Malignant Thyroid Pathology in the Molecular Follicular variant of PTC Era NIFT-P Follicular carcinoma Jennifer L. Hunt, MD, MEd Aubrey J. Hough Jr, MD, Endowed Professor of Pathology Chair of Pathology and Laboratory Medicine University of Arkansas for Medical Sciences [email protected]

“In pursuit of the low grade malignancy”

1 2

Benign

Indeterminant

Malignant

Follicular Variant of Papillary Follicular Variant

Histology: Definition Pure follicular architecture 1980 1985 1990 1995 2000 2005 Papillary carcinoma nuclei

Chen KTK, Rosai J. Follicular Growth Pattern variant of thyroid papillary carcinoma: A clinicopathologic Invasive and infiltrative study of six cases. American Journal of Surgical Pathology, 1(2): Encapsulated 123, 1977.

Juan Rosai

5 6

201 Invasive follicular variant PTC Encapsulated follicular variant PTC

Conventional papillary carcinoma Abortive papillae

Encapsulated Follicular Variant

Low power clues Nuclear atypia at 4X Clustered nuclear atypia Nuclear features better under capsule Peri-follicular fibrosis Dense colloid

11 Follicular variant PTC

202 Encapsulated Follicular Variant

High power clues: Nuclear atypia Flattened, pushed in, irregular nuclear contours Peripheral condensed chromatin Small peripheral nucleoli

Follicular variant PTC 14

Follicular variant PTC Follicular variant PTC

Encapsulated Follicular Variant

Borderline nuclear atypia: not perfect FVPTC Patchy nuclear atypia: Good nuclei, but very non-uniform distribution

17 Follicular variant PTC

203 Patchy features Patchy features

The Problem Attempts to Resolve

We all know that most of these tumors Improving diagnosis behave well. Special stains Some have nodal metastases Molecular markers Rare cases have distant metastases Changing practice patterns Changing terminology

“In pursuit of the low grade malignancy”

21 22

Immunohistochemistry Immunohistochemical Stains

Stains might be useful, when. 100% Nuclear features are incomplete 90% 80% Nuclear features are only patchy 70% Stains are not diagnostic, they are only 60% CK19 supportive 50% HBME 1 40% Galectin 3 30% CD 56 20% 10% 0% Follicular Follicular Hurthle cell Papillary adenoma carcinoma carcinoma carcinoma

23 Dunderovic, Diagnositc Pathology 10:196; 2015 24

204 Immunohistochemical Stains

100% 90% 80% 70% 60% CK19 50% HBME1 40% Galectin 3 30% HBME/CK19 20% 10% 0% Classic PTC FVPTC Follicular adenoma

Scognamiglio T, AJCP, 126:700,2006 25 Incomplete and patchy nuclear features

Molecular Mutations in Thyroid Cancer

Papillary carcinoma BRAF gene mutations RET/PTC translocations RAS mutations Follicular carcinomas RAS mutations PPARγ/PAX8 translocations

CK19 HBME 27 28

BRAF Gene Mutations BRAF Mutations in Thyroid Lesions

Oncogene Activating mutation in exon 15 Thyroid cancer T1799A (Nucleotide: T > A) V600E (Codon: Valine > glutamate) Also seen in other tumors Colon cancer (nonhereditary MSI cancers) Melanomas

29 30

205 New Development RAS Gene Mutations

Mutation specific BRAF antibody (VE1) Oncogene Recent study of brain metastases Activating mutations 55% of metastatic melanoma NRAS and HRAS: Codon 61 33% of metastatic thyroid KRAS: codons 12, 13, 61 Another study showed perfect match between Also seen in other tumors mutation status and staining Colon carcinoma Lung carcinoma Others

31 32

RAS Gene Mutations Translocations

RET/PTC Translocations 100% Up to 15 different partner genes ELE1 and H4 most common 80% More common in radiation papillary carcinoma 60% Difficult to detect (intra-chromosomal rearrangement) 40% PAX8-PPARγ Translocation 20% Relatively specific to follicular carcinoma

0% FVPTC Conv PTC FA FCC

33 34

BRAF Mutation and Sensitivity BRAF Mutation in FNA

100.00% 100% 80.00% 80%

60.00% FNA (s) 60% FNA+BRAF (s) 40.00% 40%

20% 20.00%

0% 0.00% Atypical Suspicious Follicular Marchetti Zatelli Kim SW Pellizzo neoplasm

35 36

206 Reported Molecular Profiles Commercial Assays

Gene expression array testing

Category Name RAS BRAF RET/ PAX8/ Mutation panel approach PTC PPAR Conventional Papillary Ca 10-20% 50-75% ~30% 0

Follicular carcinoma ~30-50% 0 0 ~30-35%

Follicular Adenoma ~30% 0 0 ~5-10%

Follicular Variant PTC ~25% ~5% ~5% ~35%

37 38

Expression Array Assay Panel Based Testing

Proprietary assay: 142 gene expression Commercial assay markers are not published Laboratory Developed Tests can also be Most published studies are industry obtained sponsored Performance characteristics are difficult to assess

39 40

<1% risk 5-10% risk 20-30% risk 50-75% risk

<1% risk 5-10% risk 20-30% risk 50-75% risk Thyroid Fine Needle Aspiration Lobectomy

Benign Molecular Suspicious Molecular Result Result Total Thyroid 7% risk 47% risk

207 The Real Question Attempts to Resolve

Will the results of the molecular test Improving diagnosis change the treatment algorithm? Special stains Will some patients be spared unnecessary Molecular markers surgery? Changing practice patterns Will some patients be given more extensive (appropriate) surgery? Changing terminology Will there be overall cost savings?

43 44

Chernobyl Classification FVPTC New Proposed Terminology

“Non-invasive follicular thyroid neoplasm Category Name Atypical Invasion Nuclei with papillary-like nuclear features Follicular Adenoma X X 24 pathologists Follicular carcinoma X Yes 109 thyroids Well differentiated carcinoma, NOS Questionable Yes Retrospective analysis with 10-26 years follow- Well differentiated tumor of UMP Questionable X up Follicular tumor of UMP X Questionable

For consensus classification, not for diagnostic and clinical utility

Williams ED, Int J Surg Pathol 2000;8:181. 45 NIkiforov, JAMA Oncology 2(8):1023, 2016 46

NIFT-P Criteria Dissecting “Indeterminants”

Follicular growth pattern (<1% papillae) Thyroid nodule management No psammoma bodies “Indeterminants”: Benign vs. Malignant Encapsulation or clear demarcation Follicular variant of PTC Nuclear score 2-3 Follicular carcinoma No vascular or capsular invasion No tumor necrosis <30% solid, trabecular, insular growth No high mitotic activity (high=3 /10 HPF) “In pursuit of the low grade malignancy”

47 48

208 Follicular carcinoma, NOS

Minimally Widely Invasive Invasive

Minimally Encapsulated Invasive Angio-invasive

Thin capsule Intermediate capsule Thick capsule49

Mortality in Follicular Tumors Follicular carcinoma

Minimally Invasive, encapsulated Capsular Vascular Widely Measured By definition: Capsular invasion invasion invasion invasive Diagnostic Clues Thick capsule Van 0% 28% N/A Disease specific mortality Dystrophic calcifications Heerden Avoid FNA track pitfall (1992) D’Avanzo 2% 20% 62% 5-year mortality (2004)

Van Heerden, Surgery 112:1130, 1992 D’Avanzo, Cancer 100:1123, 2004

51 52

Not Capsular Invasion 54

209 Capsular Invasion Capsular Invasion

Capsular Invasion Diagnostic Clues: FNA track

Follicular carcinoma

Angio-invasive, encapsulated By definition: Vascular invasion At or beyond level of tumor capsule Medium to large sized vessels Reaction around tumor thrombus Endothelialization Fibrin deposition Capsular invasion may be present Diagnostic clues Tumor present within capsule

Diagnostic Clues: FNA track 60

210 Not Vascular Invasion

Vascular Invasion Vascular Invasion 64

Vascular Invasion

211 Diagnostic Clues: Capsular Vessel Diagnostic Clues: Vascular Invasion Right angle turns Tumor with right angle turns

Diagnostic Clues: Vascular Invasion Tumor with right angle turns Diagnostic Clues: Vascular Invasion 70

Diagnostic Clues: Vascular Invasion Diagnostic Clues: Vascular Invasion Tumor with right angle turns Strips of tumor within and parallel to capsule

212 Follicular carcinoma NIFT-P

Widely invasive Follicular growth pattern (<1% papillae) Multifocal invasion throughout thyroid No psammoma bodies Invasion outside of the thyroid Encapsulation or clear demarcation Nuclear score 2-3 No vascular or capsular invasion No tumor necrosis <30% solid, trabecular, insular growth No high mitotic activity (high=3 /10 HPF)

73 74

Implications of NIFT-P My 2 Cents

“A very low risk of adverse outcome when I infrequently use NIFT-P, because the tumor is non-invasive” Some lesions have papillae Some lesions have some invasion or are suspicious for invasion Some lesions have increased mitoses or nuclear atypia

Most common use: lesions I used to think were adenomas with atypia

75 76

Summary

Follicular variant “Non-invasive follicular neoplasm with papillary like nuclear features” (NIFT-P) Follicular carcinoma

213 214 215 216 Pattern Based Diagnosis and Evolution of the Classification of Renal Cell Neoplasia Classification of Renal

2016 Tumors Papillary adenoma Oncocytoma Clear cell renal cell carcinoma Multilocular cystic clear 2004 cell renal cell neoplasm of low malignant potential Papillary adenoma Papillary renal cell carcinoma Ming Zhou, MD, PhD Oncocytoma Chromophobe renal cell Clear cell renal cell carcinoma Dr. Charles T. Ashworth Professor of Pathology carcinoma Carcinoma of the collecting WHO 2016 Multilocular cystic clear cell ducts of Bellini Director, Anatomic Pathology 1981 renal cell ca Renal medullary carcinoma Papillary renal cell MiT family translocation renal carcinoma cell carcinoma The University of Texas Southwestern Medical Center Adenoma Chromophobe renal cell Mucinous tubular spindle cell Carcinoma carcinoma carcinoma Dallas, TX Renal cell ca Carcinoma of the collecting Tubulocystic renal cell 1920-1960 Other ducts of Bellini carcinoma [email protected] Renal medullary carcinoma Acquired cystic disease- Xp11 translocation renal associated renal cell Renal cell ca cell carcinoma carcinoma Carcinoma associated with Clear cell papillary renal cell 1880-1920 neuroblastoma carcinoma Mucinous tubular spindle Hereditary leiomyomatosis cell carcinoma renal cell carcinoma Hypernephroma Hereditary leiomyomatosis syndrome-associated RCC Grawitz tumor renal cell carcinoma SDH deficient renal cell syndrome-associated RCC carcinoma Renal cell carcinoma, Renal cell carcinoma, unclassified unclassified

Frequency of Histological Subtypes Accurate Classification Is Critical for of Renal Tumors Patient Management!

(260 Tumors from NYU, 2014) Prognosis Benign- oncocytoma Indolent- HOT, clear cell papillary RCC Malignant, low grade- chromophobe RCC Malignant, high grade- HLRCC Hereditary/syndromic associations HOT- Birt-Hogg-Dube SDH deficient RCC- hereditary paraganglioma- pheochromocytoma syndrome HLRCC Therapeutic implications Clear cell RCC- high dose IL-2, VEGF-targeted therapy, TKI, mTOR inhibitors Papillary RCC- MET inhibitors

Morphological Classification of Renal Tumors Morphological Classification Requires A Inherently Not Precise Methodical, Pattern-based Approach

1. Look for predominant pattern at low power Same pattern may be seen in different 2. Generate differential diagnosis based on the tumors predominant pattern Same tumor may have two or more 3. Rule in or out each tumor on the list by different patterns looking for a constellation of histological Poorly differentiated tumors may not have features relatively specific for the tumor a distinct pattern or architecture 4. Use ancillary diagnostic tools 1. Immunohistochemistry 2. Genetic studies

217 Clear cell/pale cytoplasm Papillae lined with clear cells Morphological Classification Requires A Methodical, Pattern-based Approach

1. Look for predominant pattern at low power 2. Generate differential diagnosis based on the predominant pattern 3. Rule in or out each tumor on the list by Tubulopapillae lined with blue cells Pink cell looking for a constellation of histological features relatively specific for the tumor 4. Use ancillary diagnostic tools 1. Immunohistochemistry 2. Genetic studies

Histological Patterns of Renal Tumors Morphological Classification Requires A Methodical, Pattern-based Approach Tumors with clear (light-staining) cytoplasm 1. Look for predominant pattern at low power Clear cell RCC 2. Generate differential diagnosis based on the Clear cell papillary RCC predominant pattern Multilocular cystic renal tumor of LMP 3. Rule in or out each tumor on the list by RCC with smooth muscle stroma Papillary RCC with clear cells looking for a constellation of histological Chromophobe RCC, classical form features relatively specific for the tumor Translocation RCC 4. Use ancillary diagnostic tools Pelvic urothelial carcinoma 1. Immunohistochemistry Epithelioid AML 2. Genetic studies Intrarenal adrenal tissue

Tumors with clear (light-staining) cytoplasm Case 1 Immunohistochemical Work-up 25 year-old female with back pain AE1/3 GATA3 CD10 CK7 CA9 KS-Cad TFE3 HMWCK Abdominal CT Cam5.2 p63 Bilateral renal masses CCRCC Complex cystic lesions with multiple enhancing ChRCC septations and peripheral calcifications Systemic work-up negative CCPRCC Left partial nephrectomy followed by right Translocation RCC radical nephrectomy 6 months later TCC

218 Renal Tumors with Tubulopapillary Architecture lined with basophilic cells

Papillary RCC, type 1 Metanephric tumors, including metanephric adenoma Wilms tumor, differentiated type (epithelial predominant Wilms tumor)

Metastatic adenocarcinoma (especially papillary thyroid ca)

219 Papillary RCC, type 1 Papillary RCC, type 1

Metanephric adenoma Metanephric adenoma

220 Epithelial Wilms tumor Epithelial Wilms tumor

Histological Features of PRCC, WT and MA PRCC WT MA Tumor Capsule

Tumor capsule + + -

Nuclei Variable Columnar Oval bland Fine chromatin No nucleoli Inconspicuous nucleoli PRCC Mitosis rare common absent WT MA Histiocytes ++ + +

Psammoma body + + +

Hemosiderin + + +

Other components Tubulo-pap Blastemal Stromal + hyperplasia stromal

PRCC Immunohistochemical Profiles of PRCC, Nuclear Features WT and MA

PRCC WT MA AE1/3 100% 29% 50% CK7 78% 30% 7% CD56 0 100% 0 WT MA CD57 4% 7% 89% AMACR 98% 0% 10%

WT-1 10% 81% 82% BRAF V600E (VE1) 0 0 95% Cadherin 17 0 0 81%

221 Metanephric Adenoma BRAF VE1 Histological and IHC Features of PRCC, WT and MA

PRCC WT MA

Tumor capsule + + -

Nuclei Variable Columnar Oval bland Fine chromatin No nucleoli Inconspicuous nucleoli

Calio et al, Oncotarget 2016 Mitosis Rare Common Absent

CK7 + + -

CD56 - + - CD57 - - + WT-1 - + +

BRAF VE1 - - +

Yakirevich E et al, AJSP 2015

Case 1

• Thick fibrous capsule with infiltration Diagnosis: into perinephric fat • Low columnar nuclei with rare mitosis Adult Wilms tumor, differentiated type • Immunohistochemistry CK7: focal (Epithelial predominant Wilms tumor) CD56: + AMACR – WT-1: +

Renal Tumors with Tubulopapillary Architecture lined with basophilic cells (Summary) Case 2

Papillary RCC, type 1 Metanephric tumors, including metanephric adenoma 64 year old male Wilms tumor, differentiated type (epithelial CT scan showed a 2.5 cm mass in right predominant Wilms tumor) kidney Partial nephrectomy Metastatic adenocarcinoma (especially papillary thyroid ca)

222 Histological Patterns of Renal Tumors

High grade infiltrative tumors

Collecting duct carcinoma Medullary carcinoma Hereditary leiomyomatosis/RCC syndrome Urothelial carcinoma Any (super-)high grade RCC (periphery) Metastatic carcinoma

Collecting Duct Renal Cell Carcinoma

Diagnosis of exclusion (r/o entities included in the DDX of high grade infiltrative tumors) PAX8+/HMWCK+/GATA3-/Ini-1+

223 Medullary Carcinoma

Sickle cell trait and related hemoglobinopathies Highly aggressive disease Morphology similar to collecting duct carcinoma Sickle cells Ini-1 -, OCT3/4+

Hereditary Leiomyomatosis/RCC Syndrome Urothelial Carcinoma Involving the Kidney

Germline mutation in fumarate hydratase gene (1q42) Multiple skin leiomyomas, uterine fibroid and leiomyosarc “type 2” PRCC Prominent “CMV inclusion” or melanoma like nucleoli

High Grade Clear Cell RCC Metastasis from Lung Squamous Cell Carcinoma

Periphery of the tumor More classical area may be identified after extensive sampling

224 Renal Tumors with High Grade Infiltrative Work up a renal tumor with “high Growth Pattern grade infiltrative growth” PAX8 + - + (Mullarian)

1. Clinical history CK7/CK20/K903/GATA3 - Lineage specific markers TTF-1/CDX2/ER/PR/WT-1

2. Immunohistochemistry CK7+ CK7+ Variable staining CK20+ CK20- pattern K903+ K903+ GATA3+ GATA3- +

High grade RCC, TCC CDC Met Ca unclassified

CK7 PAX8

TTF-1

Diagnosis

Lung adenocarcinoma metastatic to the kidney

225 Case 3

High Grade Infiltrative Renal Tumors 45 year-old male with abdominal pain (Summary) Abdominal CT: right kidney mass Right radical nephrectomy Collecting duct carcinoma Gross pathology Medullary carcinoma upper pole Urothelial carcinoma 8x7x4 cm circumscribed mass Any (super) high grade RCC yellow-tan bosselated cut surface Metastatic carcinoma

Histological Patterns of Renal Tumors Pink cell tumor

Clear cell RCC with granular cytoplasm Oncocytic papillary RCC Chromophobe RCC, eosinophilic variant Oncocytoma Translocation RCC RCC associated with end stage renal disease Succinic dehydrogenase deficient RCC Hybrid oncocytic tumor (HOT) in Birt-Hogg-Dube syndrome (BHD) Eosinophilic solid cystic RCC Adrenal cortical tumor Epithelioid angiomyolipoma

226 Always consider and rule out epi-AML Always consider and rule out epi-AML for a high grade pink cell tumor for a high grade pink cell tumor

Ganglion –like cells Multi- nucleated giant cells

Immunohistochemistry Diagnosis

Cytokeratins – Epithelioid Angiomyolipoma EMA- PAX8- Melan A+ HMB45 + (focal)

Diagnosis of “Pink Cell Tumors” Diagnosis of “Pink Cell Tumors” Morphology Tip

Morphology 1. Do extensive tissue sampling to look for + “low grade”, better differentiated areas to make a diagnosis IHC

227 Clear Cell RCC with “Granular Cytoplasm” Oncocytic Papillary RCC

Sharp circumscription, no capsule, entrapped renal tubules: benign or low grade tumor (oncocytoma/ChRCC) Diagnosis of “Pink Cell Tumor” Morphology Tip

2. Look at tumor/normal interface and capsule

Chromophobe RCC

Diagnosis of “Pink Cell Tumor” Papillary RCC Morphology Tip

3. Look at the cell borders/cell membrane

228 Distinct, thick cell borders (plant-like): ChRCC Separation between cells: Oncocytoma

Eosinophilic cytoplasmic globules: Clear cell RCC Diagnosis of “Pink Cell Tumor” Morphology Tip

4. Look for cytoplasmic features

Cytoplasmic vacuoles: Succinate dehydrogenase (SDH) deficient RCC Pericellular fibrosis: translocation RCC

229 Diagnosis of “Pink Cell Tumor” Morphology Tip

5. Look for nuclear features

Nuclear/cytoplasmic synchronization: Clear cell RCC

No nuclear/cytoplasmic synchronization: Not Clear cell RCC (oncocytoma) Raisinoid nuclei with perinucleolar halos: ChRCC

Multinucleated giant cells: Epithelial AML Diagnosis of “Pink Cell Tumor” Morphology Tip

6. Other features

230 TFEB translocation RCC Calcium oxalate crystals: Acquired cystic disease associated RCC

Pink Cell Tumors Diagnosis of “Pink Cell Tumors” Immunohistochemical Work-up

Markers CK7 CAIX AMACR CD117 Diagnosis Morphology CCRCC with granular - + -/+ - + cytoplasm IHC PRCC, oncocytic type -/+ - + - ChRCC, eosinophilic + - -/+ + type Oncocytoma + - - +

Histological Patterns of Renal Tumors Pink cell tumor (Summary) Questions?

Clear cell RCC with granular cytoplasm Oncocytic papillary RCC Chromophobe RCC, eosinophilic variant [email protected] Oncocytoma Translocation RCC RCC associated with end stage renal disease Succinic dehydrogenase deficient RCC Hybrid oncocytic tumor (HOT) in Birt-Hogg-Dube syndrome (BHD) Eosinophilic solid cystic RCC Adrenal cortical tumor Epithelioid angiomyolipoma

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2nd Annual Surgical Pathology Update: Diagnostic Pearls for the Practicing Pathologist September 14 - 15, 2017 The Venetian® | The Palazzo® • Las Vegas, NV

39th Annual Seminar Pathology Review February 11 - 16, 2018 The Westin Snowmass Resort • Snowmass Village, CO

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