Questions and Answers Only
SLIDE 33 UTERUS, LEIOMYOMAS (LEIOMYOMATA)
Questions for slide 33:
1. Which of the following terms are applicable to this slide: tumor, neoplasm, cancer, hamartoma.
All except cancer and hamartoma.
Tumor = any mass or lump
Neoplasm = "new growth"; exhibits uncontrolled proliferation i.e. growth is excessive and uncoordinated with the rest of the body and persists after cessation of the stimulus that produced it is gone; autonomous.
Cancer = any malignant tumor.
Hamartoma = disorganized mass of normal tissue components that arise from congenitally misplaced groups of cells and is not a true neoplasm.
2. How is this lesion different from hypertrophy and hyperplasia?
Neither term indicates neoplasia and both are types of adaptation to increased demand or hormonal stimulation. Hypertrophy = increase in size of cells, hyperplasia = increase in number of cells. Both are usually more widespread or diffuse changes in the given tissue or organ.
3. How would this neoplasm's characteristics compare to a malignant neoplasm in the following areas: rate of growth, manner of growth, metastasis, effect on patient?
rate of growth = slower
manner of growth = expansile, displacing adjacent tissue, not invasive, compressing, but not destroying adjacent tissue
metastasis = none
effect on patient = usually not dangerous except because of location, or complications or hormone production
What histologic features support a low rate of growth and an expansile manner of growth in this slide? What nuclear features indicate a benign tumor?
Low rate of growth: best indication is few or no mitoses but also no nuclear hypertrophy, no nuclear enlargement, no enlarged nucleoli and no increased N/C ratio
Expansile growth: well circumscribed with compressed but not invaded surrounding myometrium.
Benign Nuclear Features: rare or no mitoses which are normal; nuclei of tumor cells resemble surrounding myometrium with no pleomorphism, no hyperchromasia, and normal nucleoli.
4. Is this tumor a mesenchymal tumor or an epithelial tumor? mesenchymal tumor. Does the cytoplasm or nucleus help most in that determination? cytoplasm primarily, but nuclear shape can help. What types of cells classified as "epithelial cells" in histology form mesenchymal tumors? endothelial and mesothelial cells
5. Why is this lesion called a leiomyoma?
benign tumor derived from smooth muscle
6. What effects did this neoplasm have in the patient? menorrhagia, causing anemia and fatigue; mass effect causing constipation and urinary frequency. Could these same symptoms be found in a malignant tumor? Symptoms could be found in malignant tumor.
Slide 105 UTERUS, LEIOMYOSARCOMA
Questions for slide 105:
1. There are specific criteria for diagnosing malignancy in smooth muscle tumors in the uterus that you have not had. However, there are many general features in the slide that indicate the tumor is malignant. What are these general microscopic features? In most cases are nuclear or cytoplasmic features more helpful in detecting malignancy?
General features: Poorly defined, invasive or infiltrative margin; increased cellularity; pleomorphism, nuclei enlarged, hyperchromatic with coarse chromatin and variable nucleoli; many mitoses some of which are abnormal; (areas of necrosis and hemorrhage)
In general, in the cytodiagnosis or in the evaluation of individual cells the nuclear features more helpful than the cytoplasmic features in detecting malignancy. Of overall features and not merely cellular features, metastasis is the most reliable criterion for malignancy and invasiveness is the second most reliable feature.
2. Why do you think the patient felt weak and tired?
Anemia from blood loss
Is this related to the tumor in any way? yes, tumor eroding into endometrial cavity and bleeding
What are some other general effects of neoplasms? Mass effect causing obstruction (gut, bronchus, ureter, etc), irritation (cough, indigestion, dysuria, etc), ulceration (can be 2ndarily infected or hemorrhage), interfering with hormonal or other secretions (obstruct excretory gland ducts or replace or destroy endocrine glands); rupture or infarction of tumor; systemic effects such as malaise and low grade fever, and anemia of chronic disease (even without iron deficiency); cancer cachexia are some effects any cancer may cause. Many of the mass effects can also be caused by benign tumors. Other more specific effects depending on tumor type are hormonal secretion, and paraneoplastic syndromes.
3. The surgeon evaluated the patient for metastases. What is a metastasis and where would be likely sites for metastases in a patient with a leiomyosarcoma? Metastasis = discontinuous spread of a neoplasm to produce secondary tumor growths more of less distant from the primary tumor. Lung, bone and brain are common sites for leiomyosarcoma of the uterus. Why? Sarcomas are more likely to spread by hematogenous routes or direct invasion than lymphatic. The venous drainage of the uterus is via the iliac veins into the inferior vena cava and thus bypasses the liver and returns to the heart where it is distributed to the lung where most initial metastases occur. Further spread can then occur via the left heart.
What factors are involved in staging? Factors in staging: assessment of extent of tumor spread. Criteria include tumor size, extent of local growth (within or outside the organ of origin), presence of lymph node or distant (usually hematogenous) metastases. Do they apply to carcinomas as well as sarcomas? With specific tumors the criteria may vary somewhat but these same factors are in general applicable to both carcinomas and sarcomas
4. What features are used to grade cancers? Indicate which of these features are found prominently in this tumor.
Grading cancers = attempts to predict the clinical behavior of malignant tumors and to establish criteria for therapy. Features are histologic/cytologic including assessment of anaplasia (presence or lack of differentiated features), and assessment for the rapidity of growth and the degree of abnormality of growth (number of mitoses, abnormal mitoses, pleomorphism) All these features would be present in this tumor in some regions.
5. The fact that the tumor is a sarcoma indicates the tumor is of what origin? mesenchymal
6.. Why do you think the necrosis occurred? outgrew blood supply
Slide 193 PARATHYROID GLAND, ADENOMA
Questions:
1. What gross clinical feature indicates that this organ is an adenoma and not a hyperplasia? only one gland involved
2. What microscopic features are those of a benign epithelial neoplasm?
close resemblance to normal tissue without pleomorphism, anaplasia, or nuclear changes
3. Would the hypercalcemia be considered a paraneoplastic syndrome?
no. parathyroid glands normally secrete parathormone. Paraneoplastic syndrome is the elaboration of hormones that are not indigenous to the tissue from which the tumor arose
4. Why is the lesion considered an adenoma since the tumor does not form glands? An adenoma is a benign tumor of glandular (in this case endocrine gland) epithelial cell origin. Many adenomas will be benign tumors with glands but many benign endocrine tumors will not form glands but are considered adenomas since they arose from glandular epithelium.
Slide 40 LUNG, SQUAMOUS CARCINOMA (EPIDERMOID CARCINOMA)
Questions for slide 40:
1. What features of malignancy are present: Is there active cellular proliferation? yes, there is nuclear enlargement and nucleoli and mitoses and some increase in N/C Evidence of abnormal cellular proliferation? yes, there are many hyperchromatic nuclei, clumping and clearing of chromatin and abnormal nuclear membranes with pleomorphism Is the tumor circumscribed, encapsulated or invasive? invasive Is there evidence of loss of cellular specialization or differentiation? yes, while most of the tumor shows differentiation and not anaplasia (lack of differentiation), some areas of the tumor look more undifferentiated with no keratinization, loss of cohesion, and no intercellular bridges
2. What features tell you the tumor arose from stratified squamous epithelium or is differentiating into a squamous (epidermoid) carcinoma and not an adenocarcinoma or an undifferentiated carcinoma? Tumor is composed of nests and sheets of polygonal cells with intercellular bridges and foci of keratinization. In some of the best differentiated areas the tumor cell clusters are surrounded by more closely spaced cuboidal cells resembling the basal layer of str. sq. epithelium and the cells gain cytoplasm and appear to mature as they approach the center where they sometimes are keratinized, form keratin pearls, and have well formed intercellular bridges.
3. If the tumor infiltrated into the pleural cavity and into the chest wall, it would be what pattern of spread? direct extension (not metastasis)
4. What is a metastasis? How does it result? defined previously. It results from tumor invading lymphatics or blood vessels (usually veins) from where they are carried to a new location and lodge in the microcirculation and grow autonomously. Survival of the tumor emboli depends on many factors.
5. In this case what would be the most likely site of the earliest metastasis? mediastinal hilar lymph nodes (lymphatic spread is most common pathway for initial spread of carcinomas)
6. If the hilar nodes were enlarged on chest x-ray, should a resection of the lung primary be dismissed because of evidence of metastasis? no, might be inflammatory
7. From this tumor where would be possible sites of hematogenous metastases? brain, bone, liver, adrenal etc. any organ or site possible
8. Explain the patient's clinical symptoms of chronic cough, hemoptysis, 20 pound weight loss, and hypercalcemia. cough=bronchial irritation, hemoptysis=tumor eroding blood vessels and/or necrosis of tumor with hemorrhage, 20 lb weight loss=cancer cachexia, hypercalcemia=paraneoplastic syndrome
9. The patient was diagnosed by cytology. What is another common method of diagnosis which could have been used in this patient. bronchial biopsy What advantage does each method have? cytology=rapid, inexpensive, simple, less invasive, minor tissue injury. surgical biopsy=less subjective, interrelationships of cells and stroma intact, size and location of lesion may be approximated in some types of biopsies.
10. Are there any common tumor markers that could be monitored in the patient's plasma for recurrence? not commonly If the tumor had been poorly differentiated, are there any immunocytochemistry stains that could be performed to confirm the tumor is epithelial in origin? cytokeratins What must be true of tumor antigens to make them useful as plasma monitors of a tumor sensitive and specific
.
11. What is the most likely predisposing factor in this patient's cancer? smoking
12. Is squamous cell carcinoma the most common cause of cancer in men? This probably should have read: Is lung carcinoma the most common cause of cancer in men? ans. excluding skin cancers, prostate is most common cause in men In women? breast carcinoma is the most common cause of cancer in women Is it the most common cause of death in either? both
Slide 44 COLON, ADENOCARCINOMA
Questions:
1. Are colorectal carcinomas common in men and women? yes What is a more common cause of cancer death? lung
2. What features tell you the tumor is malignant? Gross: infiltrating through wall. Micro: see above answers
3. What features tell you the tumor is a carcinoma and not a sarcoma? Arises from colonic epithelium and the cells forms cohesive nests, etc.
4. What features tell you the tumor is an adenocarcinoma and not some other type of carcinoma? Is forming glands
5. What does the presence of lymphocytes around the tumor suggest? it has been suggested that the lymphocytes are responding to tumor antigens.
6. What tumor associated antigen is likely to be found in this patient's plasma as a tumor marker? CEA Name other tumor markers and tumors they are commonly associated with. alpha-Fetoprotein=liver cell carcinoma and nonseminomatous germ cell tumors of the testis, prostatic acid phosphatase=prostate
7. If the patient had a tumor associated antigen (tumor marker), how might it be useful after surgery. Checking for adequacy of treatment, presence of metastases and recurrence
8. If an immunocytochemical stain were done on this tumor which of the following would you expect to be positive: CD45, cytokeratin, vimentin, desmin, glial fibrillary acidic protein, or neurofilament proteins, prostatic acid phosphatase, alpha-fetoprotein? cytokeratin Name a tumor in which each of the above antigens or markers would be expected to be positive. CD45--leukemia, lymphoma, cytokeratin--epithelial cells and carcinomas, vimentin--mesenchymal cells and sarcomas (some carcinomas), desmin--smooth and skeletal muscles and their neoplasms, glial fibrillary acidic protein--glial cells and gliomas, neurofilament proteins--neurons and paraganglia cells and their neoplasms Note that not all antigens that are found in tumors are useful as tumor markers in the plasma.
Slide 194 LIVER, METASTATIC SMALL CELL UNDIFFERENTIATED CARCINOMA
Questions:
1. Is this tumor pleomorphic? Not too much
2. Is this tumor anaplastic? yes
3. What other features of a high grade malignancy are present? extensive replacement of hepatocytes by tumor, many mitoses, hyperchromasia, lack of cohesion of tumor cells
4. What paraneoplastic syndrome is this carcinoma sometimes associated with? ACTH production
5. Why is the tumor called an undifferentiated carcinoma? despite the extremely poor differentiation, making it undifferentiated (can't tell tissue of origin) there is some cell cohesion, though not much, allowing it to be called a carcinoma
6. Why in the gross picture is the liver green near the tumor nodules? bile stasis from blockage of canaliculi and/or small bile ducts by tumor nodules Did you see any histologic features to support this etiology? yes, canalicular cholestasis
The vascular drainage has also been obstructed by the tumor nodules and can be seen as the dilatation of the sinusoids.