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Coagulative tumor necrosis (to be distinguished from infarction, which can occur in parathyroid adenoma) 5. The presence of atypia or sarcomatous transformation has been reported, predominantly in tumors occurring in the vulva, and does not seem to predispose to recurrence (although follow-up is limited). Intensive short-term chemotherapy with intrathecal therapy results in marked improvement in survival, with overall survival of 62% at 2 years. Histologically, tumor cells have an alveolar pattern or are arranged in short cords or trabeculae. On papillae, it is sometimes so voluminous that the apical cytoplasm of the cells on one papilla touches that of the cells on an opposite papilla, creating a broad clear band between the wide cores. They can appear monomorphous or can show considerable pleomorphism, and their nucleoli can be small or prominent. However, they usually have more pronounced cytologic atypia and greater mitotic activity, including atypical forms. Iversen T, Tretli S 1998 Intraepithelial and invasive squamous cell neoplasia of the vulva: trends in incidence, recurrence, and survival rate in Norway. Invasive tumors with granular cut surfaces are almost certainly papillary carcinomas, and a block taken from the tumor is adequate. Bladder involvement may occur in patients with multiple myeloma,298 but this rarely presents a diagnostic problem in patients known to have this disease. Histologically, it is characterized by full-thickness or near full-thickness atypia. Dunphy C H 2006 Gene expression profiling data in lymphoma and leukemia: review of the literature and extrapolation of pertinent clinical applications. They have large vesicular nuclei with coarse chromatin, and some have prominent nucleoli. Inverted papilloma usually exhibits minimal cytologic atypia and mitotic activity but, in one report, 15% had "varying degrees of nuclear abnormalities and increased mitotic activity. Vera-Sempere F J, Prieto M, Camanas A 1998 Warthin-like tumor of the thyroid: a papillary carcinoma with mitochondrionrich cells and abundant lymphoid stroma. Weiss L M 1984 Comparative histologic study of 43 metastasizing and nonmetastasizing adrenocortical tumors. When a clear distinction cannot be made, a descriptive diagnosis can be rendered, such as "plasmablastic neoplasm, which can be compatible with either plasmablastic lymphoma or plasmablastic plasmacytoma/ myeloma. Besides invasion from tumors arising in the adjacent organs, the thymus and anterior mediastinal lymph nodes can be involved by metastatic tumors. Kaku T, Enjoji M 1983 Extremely welldifferentiated adenocar cinoma ("adenoma malignum") of the cervix. B, Closely packed bland-looking spindle cells merge into epithelial tubules (left field). Reticulin fibrosis of the splenic cords is also seen, and the combination of a burgeoning hematopoietic mass and compromised blood flow often produces infarcts. Ann Diagn Pathol 9: 295-297 Mete O, Asa S L 2009 Aldosterone-producing adrenal cortical adenoma with oncocytic change and cytoplasmic eosinophilic globular inclusions. Mod Pathol 10: 800-803 Moran C A, Suster S 1997 Yolk sac tumors of the mediastinum with prominent spindle cell features: a clinicopathologic study of three cases. The best differentiated cells are round and monomorphic and medium to large in size. Ottino A, Pianzola H M, Castelletto R H 1989 Occult papillary thyroid carcinoma at autopsy in La Plata, Argentina. The type of tumor present in the appendix, if any, and the histologic appearance of the tumor cells in the peritoneal mucin are important prognostic factors in pseudomyxoma peritonei, and should be described in the pathology report. Nakanuma Y, Kurumaya H, Ohta G 1984 Multiple cysts in the hepatic hilum and their pathogenesis. Dysplastic nuclear features such as nuclear pleomorphism, loss of polarity, mitotic figures, and multilayering of the epithelium can be present with both low- and highgrade morphology and suggest increased risk for malignant transformation, but stromal invasion is necessary for the diagnosis of adenocarcinoma. The key morphologic feature of lymphoblastic lymphoma/leukemia is a diffuse, dense, monomorphous infiltrate of medium-sized lymphoid cells with thin nuclear membranes, delicate chromatin, indistinct nucleoli, and a high mitotic count. Not surprisingly, aneuploidy correlates strongly with a poor prognosis, despite the fact that a few malignant tumors are diploid.

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These abnormalities are more common in pediatric patients and have been described in tumors at both pulmonary and extrapulmonary sites. This phenomenon occurs most commonly in the setting of acquired immunodeficiency syndrome. Lymphatic spread is also frequent, with involvement of lymph nodes located along the lesser and greater curvatures or around the celiac axis and abdominal aorta. Tech Coloproctol 8(Suppl 1): s214-s216 Lash R H, Hart W R 1987 Intestinal adenocarcinomas metastatic to the ovaries: a clinicopathologic evaluation of 22 cases. In this radical cystoprostatectomy a multiloculated cystic lesion replaces the entire prostate. Mitotic activity tends to be lower in clear cell carcinoma than in other types of ovarian carcinoma342; the low rate of cell proliferation has been proposed as one possible reason for the poor response to chemotherapy. Gruppo Italiano Studio Policitemia 1995 Polycythemia vera: the natural history of 1213 patients followed for 20 years. Patients with grade 1 or 2 follicular lymphoma have significantly longer overall survival than those with grade 3 follicular lymphoma, whereas the disease-specific survival is not statistically different. Other types of non-Hodgkin lymphoma, including lymphoblastic lymphoma and T-cell lymphoma, occasionally involve the ovary. Histologic Appearances PeutzJeghers polyps typically contain arborizing bands of smooth muscle, extending from the stalk between lobules of mucosa. To improve the sensitivity and specificity of the diagnosis of adenocarcinoma, a cocktail of two antibodies (p63/p504s) also has been used. If such features are present in a tumor in which no invasion is identified, an even more thorough microscopic evaluation may be warranted, with some suggesting preparation of up to two slides per centimeter of tumor diameter. The lymphoma shows edema, increased vascularity, and histiocytic infiltration, resembling granulation tissue, although many of the cells actually represent lymphoma cells. Surface Ig can often be demonstrated as well, usually IgM+, IgD-, but sometimes IgM+ IgD+. Maternal virilization is rare in women with gestational trophoblastic disease, but it occurs in about 25% of the remaining patients. The ovaries are congested and enlarged, sometimes massively, by numerous cysts measuring up to 4 cm in diameter. Kurman R J, Norris H J 1976 Endodermal sinus tumor of the ovary: a clinical and pathologic analysis of 71 cases. Cancer 58: 2224-2232 Tobinai K, Minato K, Ohtsu T 1988 Clinicopathologic, immunophenotypic and immunogenotypic analyses of immunoblastic lymphoadenopathy-like T-cell lymphoma. Cartilage is often present in immature teratomas, and determining whether it is mature can be difficult. Vollenweider R, Lennert K 1983 Plasmacytoid T-cell clusters in non-specific lymphadenitis. Clin Obstet Gynaecol 11: 239257 Buscema J, Woodruff J D 1984 Significance of neoplastic atypi calities in endocervical epithelium. MacroscopicAppearances On gross examination, adenocarcinomas vary considerably in appearance according, in part, to whether they are urachal. Urothelial carcinoma with osteoclast-type giant cells occurs more frequently in the renal pelvis than elsewhere in the urinary tract. Microscopically, several different patterns of undifferentiated carcinoma occur, sometimes in combination. Multiple nodules of tumor, some of them polypoid, protrude into the bladder lumen. Histopathology 53: 432440 9 Tumors of the Small and Large Intestines, Including Anal Canal 473 102. Farrell K, McKay P, Leach M 2011 Nodular lymphocyte predominant Hodgkin lymphoma behaves as a distinct clinical entity with good outcome: evidence from 14-year follow-up in the West of Scotland Cancer Network. Widespread vulvar involvement, as well as an increased prevalence, is associated with immunosuppression. On microscopic examination, sclerosing adenosis is characterized by an ill-defined nodule containing irregular, small acini and nests or clusters of cells embedded in a cellular stroma. The disease may regress spontaneously or may progress to chronic atrophic gastritis.


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These tumors overall have a poorer prognosis than endometrioid tumors, and the factors predisposing to their development are obscure. The stromal cores of the papillae are distended by collections of foamy histiocytes. The outlook for signet ring cell carcinoma, which is typically high stage at presentation, is worse than for other types. Diagnosis of early lesions of Kaposi sarcoma in the nodal capsule can be very difficult; there may be merely a subtle increase in some irregular vascular channels mixed with plasma cells and rare spindle cells. The tumor most often presents in the 30- to 40-year age group with a marked female preponderance. It was the consensus of the panel that attempt should be made to subtract the mucinous fibroplasia and grade the tumor based on the underlying glandular structures. Most patients are incidentally found to have lymphocytosis, lymphadenopathy, or splenomegaly. Macroscopic Appearances Wilms tumors are usually large masses more than 5 cm in diameter, and a third or more are larger than 10 cm. Rare follicular lymphomas show reversal of the normal "zonation," with the centers of the follicles being composed mostly of dark-staining small cells and the rims composed of paler larger cells. Although Waldenstrom macroglobulinemia (defined as lymphoplasmacytic lymphoma with bone marrow involvement and an IgM monoclonal gammopathy of any concentration) is common, it is not essential for diagnosis. A variety of other benign mesenchymal neoplasms that more commonly occur in the skin and subcutaneous tissue outside the genital region may also, on occasion, involve the vulva, but have no particular predilection for this site. Areas of the tumor can be replaced by hypocellular fibrovascular tissue or show necrosis accompanied by a histiocytic reaction. Of note, although the ovary may be secondarily involved, it is almost never the primary site. Papillary hidradenomas typically measure less than 3 cm and are solitary, dermal-based, dome-shaped nodules located on the labium majus or minora; occasionally multiple tumors (usually <3) may occur. Gastroenterology 114: 1206-1210 Earlam R, Cunha-Melo J R 1980 Oesophageal squamous cell carcinoma: I. Aspirate smear preparations may be helpful in evaluating cellular morphology, but the increased reticulin that is invariably associated with hairy cell infiltrates makes "dry taps" common. One type is characterized by proliferation of atypical stromal cells infiltrating between normal prostate glandular structures; the other type is proliferative change forming a single nodule. The nuclei are round and small or pyknotic and usually lack nucleoli, although they may sometimes be conspicuous. Clement P B, Young R H, Scully R E 1990 Stromal endometriosis of the uterine cervix: A variant of endometriosis that may simulate a sarcoma. In postmenopausal women, cervical polyps are highly associated with the presence of endometrial polyps, and consideration of endometrial sampling as an explanation for clinical symp tomatology (and to exclude coexistent neoplasia) is recommended. Adenomas occur throughout the colon and rectum with a fairly even anatomic distribution. It seems that most cases reported as "inflammatory pseudotumor" in the pancreas do not represent neoplastic inflammatory myofibroblastic tumors but rather a pseudotumorous manifestation of autoimmune pancreatitis (see Tumorlike Lesions). Only tumors that show stromal invasion by irregular cords and nests of tumor cells (destructive stromal invasion) or confluent expansile nodules of back-to-back glands or papillae (expansile stromal invasion) should be diagnosed as mucinous carcinoma. Marked periportal and capsular fibrosis can be seen in cases associated with vinyl chloride and thorium dioxide. It appears to be a more aggressive variant of ovarian carcinoma that warrants specific diagnosis. In noninvasive tumors, a sharp interface with the underlying normal bladder is apparent on sectioning. Nonetheless, the absolute risk among all individuals with breast implants is in fact very low. Putti T C, Bhuiya T A, Wasserman P G 1998 Fine needle aspiration cytology of mixed tall and columnar cell papillary carcinoma of the thyroid. The tumor cells exhibit marked nuclear atypia and frequent (often 30-50 or more mitotic figures per 10 high-power fields [hpf]). Endometrial stromal sarcoma frequently invades the adnexa and extends to the ovary, and stromal sarcoma is considerably more likely to develop in the uterus than the ovary.

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It has been recommended that more than three longitudinal sections should be taken for routine examination. Chan J K, Buchanan R, Fletcher C D 1990 Sarcomatoid variant of anaplastic large-cell Ki-1 lymphoma. The patients present with a mass lesion or nonspecific symptoms; some are incidentally found to harbor the lymphoma. This is an encapsulated follicular-patterned tumor with no evidence of capsular or vascular invasion. They typically are an exophytic proliferation of squamous epithelium, with acanthotic, hyperkeratotic, verrucous, or reticular subtypes of growth. Pathology the lymphoma involves the splenic red pulp in an interstitial and intrasinusoidal pattern, and the white pulp is attenuated. Sometimes the peripheral smear reveals dimorphic populations of normochromic and hypochromic cells; alternatively, normochromic, macrocytic, or normocytic anemia can be seen. Uniform cytomorphology with bland nuclei and expres sion of chromogranin are helpful distinguishing features. Because essentially no metastatic potential exists without sub mucosal invasion, some pathologists prefer not to use the designation intramucosal adenocarcinoma and in stead retain the term high-grade dysplasia for all such lesions. Intrastromal tumor cells can lie in unremarkable stroma, or they can be surrounded by inflamed or myxoid fibrous stroma. Microscopically, malignant Brenner tumor resembles a high-grade transitional cell carcinoma of the urinary tract. They involve the submucosa, are well circumscribed, and often protrude into the lumen. Tumors greater than 15 cm in diameter are too large to fit in the pelvis; they rise into and distend the abdomen and may be palpated by the patient. Young R H, Scully R E, McCluskey R T 1985 A distinctive glomerular lesion complicating placental site trophoblastic tumor. The presence of many intermingled small lymphocytes and lymphoplasmacytoid cells favors the diagnosis of lymphoplasmacytic lymphoma over plasmacytoma. These tumors are generally classified as monodermal teratomas, although the primitive ones might also be viewed as variants of immature teratoma. Gupta R, Bhatti S S, Dinda A K, Singh M K 2007 Primary melanoma of the urethra: a rare neoplasm of the urinary tract. Muller H-A, Wunsch P H 1981 Features of prostatic sarcomas in combined aspiration and punch biopsies. Young R H, Scully R E 1985 Ovarian Sertoli-Leydig cell tumors: a clinicopathological analysis of 207 cases. Invasion is infrequent in cases of low-grade papillary carcinoma and should not be diagnosed unless it is unequivocal. Dysplastic changes may be present uniformly in the nodule or noted as one or more dysplastic foci within a nodule. Adenoid Basal Carcinoma (Adenoid Basal Epithelioma) Clinical Features Adenoid basal carcinoma124134 is an uncommon tumor, representing less than 5% of cervical carcinomas. For example, colorectal cancer is cur rently the third most common cancer in both men and women in the United States and also ranks third in mor tality among cancers. The surface of the polyp may be ulcerated and acutely inflamed, showing degenerative and regenerative atypia in the epithelial and stromal cells; this can cause major diagnostic confusion because both true carcinoma. Both eosinophilic and clear cytoplasmic features often occur in the same tumor and result in a distinctive alternating pink and white appearance. A, Sheets of polygonal cells are traversed by delicate fibrovascular septa, characteristic of endocrine neoplasm. In the latter group, nuclear atypia is significant, mitotic figures are easily found, and necrosis is present; most patients die of disease. Jones M W, Silverberg S G, Kurman R J 1993 Welldifferentiated villoglandular adenocarcinoma of the uterine cervix: a clinico pathological study of 24 cases. The tumors arise in patients over a wide age range and occur more or less equally in both sexes. In addition, the accurate diagnosis of bilineage or biphenotypic leukemias requires immunophenotypic studies. Reed-Sternberg cells and variants are scattered within or sometimes also between the lymphoid nodules.

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Scully R E 2000 the prolonged gestation, birth, and early life of the sex cord tumor with annular tubules and how it joined a syndrome. Microscopically, granulocytic sarcoma consists of sheets or cords of immature hematopoietic cells with medium-sized round nuclei, fine chromatin, inconspicuous nucleoli, and scanty amphophilic cytoplasm. The stroma of a Krukenberg tumor is abundant, hypercellular, and focally edematous, and it may contain pools of mucin. No correlation of nuclear contour with cell lineage is seen in lymphoblastic lymphoma. Arch Pathol Lab Med 107: 633-637 Boggs L K, Kimmelstiel P 1956 Benign multilocular cystic nephroma: report of two cases of so-called multilocular cyst of the kidney. In such cases it may be appropriate to take the location of the tumor into account in final classification. Kovi J, Jackson A G, Jackson M A 1977 Blue nevus of the prostate: ultrastructural study. Molinie V, Herve J M, Lebret T 2004 Value of the antibody cocktail anti p63 + anti p504s for the diagnosis of prostatic cancer. Nevus cell aggregates and blue nevus formation of stellate collagen nodules (amianthoid fibers). A correlative immunohistochemical and reversetranscriptase polymerase chain reaction analysis. Mucinous cystic neoplasms are 5- to 15-cm multilocular cysts with a smooth or somewhat trabeculated inner surface. Only rarely are there symptoms attributable to ectopic hormone secretion,91 although occasionally such peptides can be demonstrated in the tumor cells by immunocytochemistry. A, the follicles comprising small cells with irregularly folded nuclei, morphologically indistinguishable from conventional grade I follicular lymphoma. Pathologic features found in malignant steroid cell tumors include large size, hemorrhage or necrosis, 2 or more mitotic figures per 10 hpf, and moderate or marked nuclear atypia. Obstet Gynecol Annu 10: 267-278 Herbst A L, Anderson D 1990 Clear cell adenocarcinoma of the vagina and cervix secondary to intrauterine exposure to diethylstilbestrol. Ali T Z, Epstein J I 2007 Basal cell carcinoma of the prostate: a clinicopathologic study of 29 cases. The Grimelius argyrophil reaction (B) also allows increased endocrine cells within the gastric glands to be identified. Oguchi K, Takeuchi T, Kuriyama M 1988 Primary carcinoma of the seminal vesicle (cross-imaging diagnosis). Renshaw A A, Gould E W 2002 Why there is the tendency to "overdiagnose" the follicular variant of papillary thyroid carcinoma. A monoclonal serum immunoglobulin is present in 80% of patients, and nearly equal numbers show a monoclonal light chain in the urine. Nuclei with fine, occasionally vesicular, chromatin patterns and inconspicuous nucleoli are typical of clear cell sarcoma. In some tumors, cords, trabeculae, or areas of diffuse tumor cell growth are present. Crawford J 1990 Pathologic assessment of liver cell dysplasia and benign liver tumors: differentiation from malignant tumors. Skelton H, Smith K J 2001 Spindle cell epithelioma of the vagina shows immunohistochemical staining supporting its origin from a primitive/progenitor cell population. Immunostains for estrogen and progesterone receptors are positive in a majority of Sertoli-Leydig cell tumors, with the most common pattern being diffuse staining for estrogen receptor and focal staining for progesterone receptor. This pattern is characterized by small to medium-sized glands that show angulations, elongation, oval shapes, irregularities in their contour, and some variation in their size. The tumor consists of an admixture of syncytiotrophoblast, cytotrophoblast, and extravillous trophoblast, with prominent hemorrhage, necrosis, and vascular invasion. Bates A W, Norton A J, Baithun S I 2000 Malignant lymphoma of the urinary bladder: a clinicopathological study of 11 cases. The papillae that occur in thyrotoxicosis, Hashimoto thyroiditis, and toxic follicular adenoma are nonbranching, short, stubby projections that protrude into the follicular lumen and lack well-defined fibrovascular cores.

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Early invasive tumors may only exhibit changes similar to highgrade precancers of the cervix on clinical examination; more advanced tumors may be polypoid or fungating or cause diffuse enlarge ment of the cervix. The best place to search for the neoplastic cells is around the necrotic foci, although distinction from histiocytes can be difficult because the nucleoli can be small. Features that distinguish AriasStella reaction from clear cell carcinoma include (1) no associated mass lesion; (2) its usually focal nature; and (3) the nuclei exhibit a spectrum of cytologic atypia. Because different nodules or zones within the tumor can represent different histologic components, which in turn may correlate with prognosis, adequate sampling of multiple areas must be undertaken. Urothelial carcinomas with squamous and/or glandular differentiation are usually high-grade, and their distinction from nonneoplastic lesions is usually easy. Handling of Specimen for Intraoperative Diagnosis In general, the diagnosis is obvious on macroscopic examination of the thyroid specimen. Ljungberg O, Bondeson L, Bondeson A G 1984 Differentiated thyroid carcinoma, intermediate type: a new tumor entity with features of follicular and parafollicular cell carcinoma. Urethral carcinoma usually occurs in patients in the sixth and seventh decades, although occasional cases have been documented in younger adults and at least one in a teenaged boy. Inflammatory cell infiltrates are relatively common in the fibrous septa and generally consist of lymphocytes, although neutrophils and eosinophils can be noted, especially around the bile ductular structures. A distinction between follicular adenoma and follicular carcinoma is not possible, because capsular or vascular invasion cannot be identified in aspirate materials. Mucin is at most rare in clear cell renal cell carcinoma, and some would categorize tumors containing mucin as renal cell carcinoma, unclassified. B, Microcystic carcinoma associated with small focus of microacinar carcinoma in a biopsy. An exceptional case of placental site trophoblastic tumor has been reported to be associated with a mature teratoma. The patients often present with fever, constitutional symptoms, hepatosplenomegaly, and pancytopenia. Rarely, signs of precocious puberty such as virilization may be the presenting feature, which is associated with production of human chorionic gonadotropin by the tumor. Hum Pathol 30: 1153-1160 Sherman M J, Hanson C A, Hoyer J D 2011 An assessment of the usefulness of immunohistochemical stains in the diagnosis of hairy cell leukemia. Insulinomatosis is characterized by the usually metachronous development of insulinomas on the background of microadenomatosis affecting the entire pancreas and showing exclusively insulinpositive microadenomas. Budin R E, McDonnell P J 1984 Renal cell neoplasms, their relationship to arteriolonephrosclerosis. Head Neck Surg 3: 409-423 21 Tumors of the Lymphoreticular System, Including Spleen and Thymus 1525 1710. The architectural changes associated with androgen deprivation therapy lead to an apparent worsening of the Gleason score compared with the preoperative biopsy results. Sometimes, they can appear deceptively cohesive, mimicking the growth pattern of carcinoma. The smooth muscle cells are typically spindle shaped, but occasionally they are polygonal or rounded with an epithelioid appearance and have abundant eosinophilic cytoplasm. Endometriosis Endometriosis involving the large intestine may present with abdominal pain, obstruction, or a mass but is some times asymptomatic. Hughes D F, Biggart J D, Hayes D 1991 Pseudosarcomatous lesions of the urinary bladder. Associated with immunosuppression: the risk of development of Kaposi sarcoma is increased in organ transplant recipients and immunosuppressed subjects. Rare mature (benign) teratomas are completely solid and can be differentiated from immature teratoma only by microscopic study. Bone marrow biopsy specimen showing proliferation mainly of the megakaryocytic lineage with increased numbers of enlarged, mature megakaryocytes. Flieder D B, Suster S, Moran C A 1999 Idiopathic fibroinflammatory (fibrosing/sclerosing) lesions of the mediastinum: a study of 30 cases with emphasis on morphologic heterogeneity. Established Kaposi sarcoma is characterized by curved intersecting fascicles of spindle cells, resulting in longitudinally sectioned fascicles juxtaposed side by side with transversely sectioned cells showing a sieve-like pattern. Occasional patients have hormonally mediated symptoms such as abnormal vaginal bleeding.

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Dickersin G R, Young R H, Scully R E 1995 Signet-ring stromal and related tumors of the ovary. Retrospective multivariate analysis of differentiated thyroid carcinoma with long follow-up. McGregor D H, Mills G, Boudet R A 1976 Intramural squamous cell carcinoma of the esophagus. Subsequently, studies have attempted to identify features associated with malignant behavior. Nodules of benign-appearing glial tissue are covered by peritoneum in this grade 0 implant. Abrupt transition is evident between the fibroma component, consisting of spindle cells with moderate cellularity, and an epithelial nodule with psammoma bodies (A). Histologic Appearances Microscopically, the septa are composed of fibrous tissue that may contain foci of calcification. Muller-Hermelink H K, Marx A, Kirchner T 1994 Advances in the diagnosis and classification of thymic epithelial tumors. Alternative Terminology An important impetus for overdiagnosis of encapsulated follicular variant of papillary carcinoma is the litigation climate, whereby the pathologist renders this diagnosis using lax criteria to avoid being sued for missing a malignancy. Deep angiomyxoma is characteristically a soft, gelatinous tumor with ill-defined margins. Carcinoma Affecting the Extrahepatic Biliary Tree Clinical Features Extrahepatic cholangiocarcinoma can be divided into tumors arising close to the hilum of the liver (perihilar cholangiocarcinoma) or in the distal portion of the bile duct (distal cholangiocarcinoma). Careful inspection of cellular morphology for dysplastic nuclear features (typically absent in aplastic anemia) and accurate blast counts can aid in this differential. Histologic Appearances Adenocarcinomas account for more than 90% of colorec tal carcinomas. The neoplastic cells are often very large and are reminiscent of large cell or anaplastic large cell lymphoma, except that the cytoplasm is typically eosinophilic and voluminous. Plasmacytomas without evidence of bone marrow involvement or generalized myeloma have rarely arisen in the bladder. The proliferative activity of partial atrophy is not significantly different from that of benign glands. The dimensions of the crowded cytologically altered gland cluster must measure at least 1 mm. The cells have vesicular nuclei with prominent nucleoli, abundant clear cytoplasm, and distinct cell membranes. Note the absence of two red signals in each of the two tumor cells, indicating a deletion at 13q14. Hum Pathol 39: 1239-1251 Soslow R A 2008 Histologic subtypes of ovarian carcinoma: an overview. Patients with Lynch syndrome have colon cancers at an average age of about 50 years, and these show a predilec tion for the cecum, ascending colon, and transverse colon. Tumor cells line glands and cystic spaces, diffusely infiltrate fibrotic stroma, or form solid nests and sheets. Peliosis of the spleen can be distinguished from hemangioma by the haphazard distribution of the irregular or round blood-filled spaces without formation of a discrete mass and the preferential involvement of the parafollicular areas. The lesions are often ulcers, erosions, or elevated lesions, often with hemorrhage and edema. The differential diagnosis includes malignant mixed tumor of the vagina, which contains a malignant epithelial and stromal component and lacks the bland biphasic appearance of spindle cell epithelioma. Kandil D H, Cooper K 2009 Glypican-3: a novel diagnostic marker for hepatocellular carcinoma and more. Serum total tryptase persistently exceeds 20 ng/mL (in the absence of a myeloid disorder that may confound this measurement) *Diagnosis of systemic mastocytosis can be made with one major and one minor criterion, or with three minor criteria.

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However, endoscopic surveillance of patients with Barrett esophagus may lead to the identification of tumors at an early stage and an improved prognosis. These tumors are composed of stellate and spindle cells in a lightly basophilic stroma. These nodules have been subclassified into a rhabdoid type, in which the tumor cells are polygonal with moderate to abundant eosinophilic cytoplasm and eccentric nuclei with prominent nucleoli; a sarcomatoid type in which the tumor cells are spindled; and a pleomorphic type in which both rhabdoid and spindle cells are present. Multilobated variant, characterized by prominent nuclear lobation, usually presents in extranodal sites. Although the stroma of Wilms tumors can differentiate in many directions, most frequently it is composed of spindle cells in an abundant faintly basophilic matrix. Problems in Classification of Thymomas and Histologic Clues the histologic clues for recognition of specific types of thymoma are listed in Table 21C-8. Hematology (Am Soc Hematol Educ Program): 245-251 Kuruvilla J, Keating A, Crump M 2011 How I treat relapsed and refractory Hodgkin lymphoma. Mucinous carcinoids can be mixed with carcinoma, and the mixed forms are the type of mucinous carcinoid most likely to spread beyond the ovary. An individual case can show features of two or more variants in the same or different nodes, and one type can evolve into another type on repeat biopsy. Very rarely, the vascular channels form plexuses or form vague or discrete nodules. Lymphocytic and histiocytic cells (arrows) are often scattered within these cellular aggregates. To be diagnosed as carcinoma in situ, the lesion should contain cells that are comparable with those of a high-grade papillary carcinoma. Immunohistochemistry for epithelial and lymphoid markers may aid in cases that are difficult to distinguish on the basis of routine stains. Tumors typically arise in the endocervical canal, into which they usually protrude, and occasionally prolapse through the os; intramural tumors may also occur. The individual or combined adrenal weight depends on various factors such as age, presence and chronicity of a variety of diseases and, most important, the effort made to carefully remove adherent connective tissue and fat before weighing the specimen. The tubules have a retiform appearance in 10% to 25% of intermediate and poorly differentiated tumors and occasionally dominate the histologic picture to the extent that it is difficult to recognize that the neoplasm is a Sertoli-Leydig cell tumor. Nearly half of the tumors are multifocal and vary from less than 1 cm to 15 cm in size. Electron microscopy studies suggest that fibromas and thecomas are derived from the same cell type and differ only in the proportion of collagen-forming and steroidforming cells. These lesions are benign, but, similar to benign cervical polyps, have the potential to recur. They are usually small and round to oval but may be convoluted, resembling collecting ducts or convoluted tubules of the kidney. Patients typically present with vaginal bleeding or discharge or symptoms related to a mass. Jorgensen L N, Chrintz H 1988 Solitary metastatic endometrial carcinoma of the spleen. Endocervical-like borderline mucinous tumors have a different immunophenotype than intestinaltype mucinous tumors. A starry-sky pattern imparted by interspersed tingible-body macrophages is highly characteristic but not pathognomonic. Monoclonal B cell populations can be found in about one third of cases, and half of these cases show a supervening intratumoral extranodal marginal zone lymphoma. It is of both practical and academic importance to recognize sclerosing adenosis, because of its remarkable resemblance to adenocarcinoma on histologic examination and its myoepithelial differentiation96,97,415,427 Normal prostatic basal cells show no myoepithelial differentiation, as has been demonstrated by Srigley. The patients present with superior vena cava obstruction or symptoms referable to the mediastinal mass, such as cough and dyspnea; only rarely do they have no symptoms. Basophils are not readily discernible in core biopsy specimens, because of loss of granules during processing, and are best appreciated in aspirate smear preparations.

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Sasatomi E, Tokunaga O, Miyazaki K 2000 Precancerous conditions of gallbladder carcinoma: overview of histopathologic characteristics and molecular genetic findings. Thymoma is sometimes adherent to the surrounding structures in the mediastinum without actual invasion; this is supported by the presence of a layer of acellular fibrous stroma between the thymoma and the adjacent anatomic structure. Kazaure H S, Roman S A, Sosa J A 2012 Medullary thyroid microcarcinoma: a population-level analysis of 310 patients. Report of two cases with anaplastic large cell morphology and plasmablastic immunophenotype. Taxy J B 1981 Renal adenocarcinoma presenting as a solitary metastasis: contribution of electron microscopy to diagnosis. Three different microscopic patterns have been described in pseudomyxoma peritonei. Cramer J D, Fu P, Harth K C, Margevicius S, Wilhelm S M 2010 Analysis of the rising incidence of thyroid cancer using the Surveillance, Epidemiology and End Results national cancer data registry. The cystic spaces often occur in the perimuscular (outer) connective tissue portion of the gallbladder wall. Note cribriform growth pattern and central rounded spaces filled with mucinous material similar to tumors of salivary gland origin. Jones J D, Pittman D L, Sandes L R 1985 Necrosis of thyroid nodules after fine needle aspiration. Benign teratomas contain a varied mixture of ectodermal, mesodermal, and endodermal elements distributed in an organized fashion. Several grading systems are available for evaluation of the extent of residual carcinoma tissue in posttherapy resection specimens. Erythroblasts are not included in the blast count except for the rare "pure" acute erythroblastic leukemias. Veress B, Nordenstrom J 1994 Lymphocytic infiltration and destruction of parathyroid adenomas: a possible tumour-specific autoimmune reaction in two cases of primary hyperparathyroidism. The presence of nucleoli, nuclear immaturity, and pleomorphism are the most reliable features of neoplastic plasma cells because multinucleation or cytoplasmic inclusions can be seen in reactive plasmacytoses. Ulbright T M 2005 Germ cell tumors of the gonads: a selective review emphasizing problems in differential diagnosis, newly appreciated, and controversial issues. Absence of glycogen and marked irregularities in the nuclear membranes favor a diagnosis of lymphoma. Analysis of the morphologic features of the large cells narrows down the differential diagnosis. Cytoplasmic mucin is demonstrable in about 50% of cases706,707; exceptionally the tumor cells may assume a signet ring appearance. To render a diagnosis of oncocytic variant of papillary carcinoma, convincing nuclear features must be present extensively as in the nononcocytic counterpart (see Table 18A-13), except that nuclear crowding may not be evident as a result of the abundance of cytoplasm. Br J Surg 40: 422-428 Melicow M M, Pachter M R 1967 Endometrial carcinoma of prostate utricle (uterus masculinus). Tumor cells typically exhibit at least focal moderate atypia, although much of the tumor may have a bland cytomorphologic appearance. Yamaguchi M, Ohno T, Kita K 1997 Gamma/delta T-cell lymphoma of the thyroid gland. Histopathology 18: 161-164 Suster S, Moran C A 1999 Micronodular thymoma with lymphoid B-cell hyperplasia: clinicopathologic and immunohistochemical study of eighteen cases of a distinctive morphologic variant of thymic epithelial neoplasm. Gallstones are found in more than 80% of patients with gallbladder carcinoma,357-359 and a true causal relationship is further suggested by the fact that gallbladder carcinoma and stones are both more common in women and Native Americans. The epithelioid cells are round or polygonal with abundant eosinophilic cytoplasm. Malignant melanoma involving the adrenal gland (primary or metastatic) is an aggressive lesion with poor prognosis.

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Peritoneal implants composed of mature glial tissue (grade 0) occur in rare patients with mature teratoma of the ovary. B, the lesion comprises spindle cells with pale nuclei and blood vessels, which are intermingled with small lymphocytes. The presence of scattered large hyperchromatic nuclei is a feature more commonly observed in follicular carcinoma than in papillary carcinoma. Histologic Appearances Wilms tumors are typically composed of variable mixtures of blastema, epithelium, and stroma, although in some tumors only two or occasionally only one component is present. Stromal sarcomas usually show high mitotic activity, tumor necrosis, and cellular pleomorphism. The lymphomatous infiltrate may occur predominantly in the subcutaneous tissue, but, in contrast to subcutaneous panniculitis-like T-cell lymphoma, some degree of simultaneous dermal involvement is always present. Rhamy R K, Buchanan R D, Spalding M J 1973 Intraductal carcinoma of the prostate gland. By convention, Gleason grading is often applied to these variants and is almost always pattern 3 or higher. Sertoli cells with bizarre atypical nuclei are present in some tumors, but this does not appear to be an adverse prognostic finding. However, this distinction is somewhat artificial in that it fails to recognize occasional cases of disseminated lymphoma with a cellular phenotype that strongly suggests origin from the gastrointestinal tract. Intimate admixture of granulosa elements containing follicles (left) and Sertoli tubules and Leydig cells (right). The oxyphilic variant of endometrioid carcinoma has a prominent component of large polygonal tumor cells with abundant eosinophilic cytoplasm and round central nuclei that contain large nucleoli. The intestinal type shows well-defined glandular structures with papillae, tubules, or even solid areas. The intervening lymphoid cells are mostly small lymphocytes with round or irregular nuclei, dense chromatin, and scanty cytoplasm. In daily practice, thecoma is an uncommon diagnosis, whereas fibromas are relatively common. Am J Surg Pathol 27: 10891103 Misdraji J 2010 Appendiceal mucinous neoplasms: controversial issues. McGregor D H, Kerley S W, McGregor M S 1993 Gastric angiolipoma with chronic hemorrhage and severe anemia. Compagno J, Oertel J E 1980 Malignant lymphoma and other lymphoproliferative disorders of the thyroid gland. Although many criteria have been defined for the diagnosis of prostate cancer in numerous previous publications, it is still difficult to apply such criteria when dealing with a small number of atypical glands. Although intracytoplasmic mucin has been described in a few cases, it is not present in the majority of cases. The diagnosis can be confirmed by a high serum parathyroid hormone level coupled with a high calcium level. The extremely rare verrucous subtype of cervical carcinoma is characteristically exophytic and composed of broadbased papillae lined by squamous epi thelium with little to no cytologic atypia. Vulvar lentigo is usually a solitary, uniformly homogeneous pigmented macule measuring less than 5 mm; however, sometimes genital lentigo may be clinically worrisome, exhibiting a more mottled appearance with irregular pigmentation and achieving a larger than usual size. Rarely, adenocarcinomas resembling intestinal or biliary adenocarcinoma can occur as primary neoplasms of the thymus. All granulosa cell tumors have malignant potential, although most do not recur or metastasize. A modification of Clark levels, as described by Chung and colleagues,123 also may be used. Tumor grade 3-5 points 6, 7 points 8, 9 points hpf, High-powered fields; mf, mitotic figures.

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