PARTICIPANT CODE:



|South East England |[pic] |

|General Histopathology EQA Scheme |7808 |

|Round b | |

|Preliminary Case Analyses | |

|Cases 647 to 658 | |

|Circulated May-June 2016 | |

|130 responses (90.28%) | |

Prepared July 2016 Authorised by: Prof J Schofield[pic] Date: 8/7/16

Please return to the EQA office by 28th July 2016

EQA Office email address: mtw-tr.EQA@

EQA Preliminary Case Consultation Instructions

Please review the preliminary results and decide whether or not any diagnoses should be merged. Merging should be considered if

• Two or more diagnoses are synonyms

• The difference between two diagnosis would not alter clinical management of the patient

Note:

• More than one combination of merges may be appropriate e.g. merging two or more malignant diagnoses together and merging two or more benign diagnoses together.

• After merging, the remaining list of diagnoses should be clinically distinct and you consider only one to be the “correct” diagnosis

Please only use the number of the diagnosis, not its full description. If you do not think any merging should be performed, then please indicate this (“merge none”)

The comments field can be used for your comments on the suitability of the case or any other comments you may have.

Please ensure you comment on every case.

Please complete the attached sheets and return to the EQA Office by the deadline date above. Any incomplete or late returns will not be accepted.

Please ensure your confidential code is entered on your form.

General notes about the consultation process

Those taking part in the Case Consultation for a round are considered the expert participant group and each expert participant will be awarded an extra CPD point per round.

Please note the purpose of consultation is not to vote for the “correct” answer. This has already been determined by the percentage agreement of submitted diagnoses and the confidence level of the diagnosis. It is perfectly possible that there may be 80% agreement to merge two benign diagnoses, but the “correct” diagnosis may be a malignant diagnosis.

ROUND: b

PARTICIPANT CODE:

Case Number: 647 Click here to view digital image

Diagnostic category: Endocrine

Clinical : M66. Fibrotic goitre post thyroiditis. Compression symptoms.

Specimen : Thyroid right lobe

Macro : Lobe of thyroid 113gm measuring 105 x 65 x 52mm. The cut surface is pale, fleshy and multinodular. No cystic or haemorrhagic areas.

| |Suggested Diagnoses |

|1 |Hashimoto’s thyroiditis |

|2 |MALT lymphoma |

|3 |Reidel’s thyroiditis |

|4 |Likely reactive but exclude lymphoma |

|5 |Marginal zone lymphoma |

|6 |Fibrosing thyroiditis |

|7 |Non-specific lymphocytic thyroiditis |

|8 |Plasma cell granuloma |

|9 |De Quervain thyroiditis (Granulomatous) |

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CASE CONSULTATION:

Please suggest diagnoses to merge (numbers only)

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Comments

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Case Number: 648 Click here to view digital image

Diagnostic category: Breast

Clinical : F47. Rupture of breast implant (PIP). Malignant transformation?

Specimen : Breast

Macro : Three irregular fragments of dark tan tissue varying between 1.2 and 2.6cm.

| |Suggested Diagnoses |

|1 |Silicone reaction & metaplasia/hyperplasia |

|2 |Silicone reaction. Hyperplasia/metaplasia not mentioned |

|3 |Synovial metaplasia & prominent macrophage reaction |

|4 |?lymphoma associated with silicone implant |

|5 |Florid inflamm reaction and reactive epithelial changes |

|6 |Xanthogranulomatous inflammation with reactive changes |

|7 |Silicone leak |

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CASE CONSULTATION:

Please suggest diagnoses to merge (numbers only)

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Comments

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Case Number: 649 Click here to view digital image

Diagnostic category: Lymphoreticular

Clinical : M21. HIV positive. Low CD4 count. Palpable lymphadenopathy right axilla ?Lymphoma ?HIV related.

Specimen : Lymph node axilla

Macro : The specimen consists of two lymph nodes, one15 x 10 x 10mm and the other 16 x 10 x 10mm.

| |Suggested Diagnoses |

|1 |HIV related lymphadenopathy |

|2 |Lymphadenopathy (HIV not mentioned) |

|3 |Progressive transformation germinal centres |

|4 |HIV related changes with probable malignant transformation |

|5 |Reactive ?infection |

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CASE CONSULTATION:

Please suggest diagnoses to merge (numbers only)

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Comments

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Case Number: 650 Click here to view digital image

Diagnostic category: GI Tract

Clinical : F77. 3/12 History of left parotid mass. FNA not diagnostic. MRI-benign neoplasm. Extracapsular dissection left parotid mass.

Specimen : Left parotid mass

Macro : An ovoid nodule measuring 38 x 18 x 16. Slicing shoes a fleshy tan cut surface with areas of haemorrhage, abutting the capsule. Immuno: CD10 positive. RCC marker negative.

| |Suggested Diagnoses |

|1 |Myoepithelioma |

|2 |Metastatic/renal cell clear cell carcinoma |

|3 |(Probably) Primary clear cell carcinoma |

|4 |Clear cell variant of other primary carcinoma |

|5 |Clear cell carcinoma NOS |

|6 |Clear cell oncocytoma |

|7 |Acinic cell carcinoma. Clear cell variant |

|8 |Clear cell tumour |

|9 |Clear cell myoepithelial carcinoma |

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CASE CONSULTATION:

Please suggest diagnoses to merge (numbers only)

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Comments

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Case Number: 651 Click here to view digital image

Diagnostic category: GU

Clinical : F54. Laparoscopic nephrectomy.

Specimen : Renal tumour

Macro : Tumour with homogenous tan surface, well circumscribed. Immuno: CK7 and ECadherin +ve; Vimentin and CD117 –ve.

| |Suggested Diagnoses |

|1 |Chromophobe RCC |

|2 |Oncocytoma |

|3 |Not answered (and no valid exemption) |

|4 |RCC |

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CASE CONSULTATION:

Please suggest diagnoses to merge (numbers only)

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Comments

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Case Number: 652 Click here to view digital image

Diagnostic category: Miscellaneous

Clinical : M6. Hard soft tissue swelling left palm - ?nature

Specimen : Soft tissue

Macro : Single irregular piece of fibrous and fatty tissue 21 x 16 x 17mm. Slicing shows a firm white cut surface.

| |Suggested Diagnoses |

|1 |Juvenile/calcifying aponeurotic fibroma |

|2 |Palmar fibromatosis |

|3 |Ossifying fibro-myxoid tumour |

|4 |Rheumatoid nodule |

|5 |Calcifying fibrous pseudotumour |

|6 |Fibroma |

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CASE CONSULTATION:

Please suggest diagnoses to merge (numbers only)

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Comments

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Case Number: 653 Click here to view digital image

Diagnostic category: Gynae

Clinical : F67. Right ovarian tumour. Bilateral salpingo-oophorectomy.

Specimen : Ovary

Macro : Ovary measures 60 x 40 x 30mm with a torn surface. On slicing there is a solid grey yellowish mass that seems to be confirmed to the ovary. There is a calcified consistency in some areas. Immuno: Positive for CAM5.2 and MNF116; negative for PLAP, TTF-1, S-100, WT-1, Calretinin, Inhibin, AFP, CK7, CK20 and Melan A. Ki67 index is less than 1%.

| |Suggested Diagnoses |

|1 |Carcinoid tumour |

|2 |Sertoli-Leydig tumour |

|3 |NET (NOS) |

|4 |Sex cord stromal tumour (Sertoli cell tumour) |

|5 |Endometrioid carcinoma/adenocarcinoma |

|6 |Metastatic carcinoma with sertoliform features |

|7 |Gonadoblastoma |

|8 |Adult granulosa cell tumour/endometrioid adenofibroma |

|9 |Leydig tumour |

|10 |Female adnexal tumour of Wolfian origin |

CASE CONSULTATION:

Please suggest diagnoses to merge (numbers only)

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Comments

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Case Number: 654 Click here to view digital image

Diagnostic category: Respiratory

Clinical : M75. Endobronchial lesion left upper lobe protruding into left main bronchus

Specimen : Lung

Macro : Left upper lobectomy 16 x 6 x 8cm. 2.8cm polypoid tumour seen protruding at bronchial resection margin, without underlying invasion. Immuno: Positive - CD10, Vimentin, CAM5.2. Negative - TTF1, P63, CK20, CK7.

| |Suggested Diagnoses |

|1 |Metastatic clear cell RCC |

|2 |Clear cell carcinoma |

|3 |Perivascular epithelioid cell (PECOMA) |

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CASE CONSULTATION:

Please suggest diagnoses to merge (numbers only)

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Comments

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Case Number: 655 Click here to view digital image

Diagnostic category: Skin

Clinical : M52. Excision of large keratotic lesion, right lower leg. 'Birth mark' previously. Had laser therapy but lesion returned very quickly.

Specimen : Skin

Macro : Skin ellipse 85 x 30 x 25mm with a 52 x 20 x 18mm warty nodule. The surrounding skin also has an irregular surface.

| |Suggested Diagnoses |

|1 |Haemangioma NOS incl spindle cell and microvenular, lobular |

|2 |Verrucous haemangioma |

|3 |Angiokeratoma (diffusum) |

|4 |Retiform haemangioendothelioma |

|5 |Other benign vascular tumour |

|6 |Unlikely malignant vascular tumour |

|7 |Angiokeratoma circumscriptum |

|8 |Arteriovenous malformation with overlying angiokeratoma |

|9 |Vascular malformation/vascular hamartoma |

|10 |Angiomatosis |

CASE CONSULTATION:

Please suggest diagnoses to merge (numbers only)

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Comments

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Case Number: 656 Click here to view digital image

Diagnostic category: Skin

Clinical : F70. Excision biopsy nodule right upper back. Clinically BCC.

Specimen : Skin

Macro : EOS 20 x 12 x 4mm with 5mm flesh coloured papule.

| |Suggested Diagnoses |

|1 |Malignant melanoma and naevus |

|2 |Malignant melanoma (naevus not mentioned) |

|3 |Intradermal melanocytic naevus with ?Paget’s disease |

|4 |Bowen’s & intradermal naevus/dysplastic naevus |

|5 |Bowen’s/SCIS (naevus not mentioned) |

|6 |In situ melanoma in a melanocytic naevus |

|7 |Invasive melanoma arising in melanoma in situ |

|8 |Extramammary Paget’s disease |

|9 |Melanocytic Intraepithelial Neoplasia |

|10 |Atypical melanocytic proliferation/lesion |

CASE CONSULTATION:

Please suggest diagnoses to merge (numbers only)

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Comments

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EDUCATIONAL CASE

Case Number: 657 Click here to view digital image

Diagnostic category: Educational

Clinical : M82 Adrenal mass. Previous anterior resection for Dukes B Ca rectum and lobectomy for lung cancer.

Specimen : Adrenal mass

Macro : Mass weighing 500g and measuring 125 x 90 x 100mm. Cut surface necrotic with no visible adrenal. Immuno: CK20, CEA and CDX2 positive; CK7 and TTFI negative.

Suggested diagnoses:

|Metastatic rectal ca |Metastatic adenocarcinoma c/w a colorectal primary |

|Metastatic Ca large bowel |Metastatic carcinoma (colorectal) - ? neuroendocrine. |

|Metastatic carcinoma, probably lower GFI tract primary |Adenocarcinoma- bowel origin |

|Metastatic colorectal adenocarcinoma |Metastatic CRC |

|Metastatic carcinoma of rectum |Adrenal gland containing metastatic colorectal adenocarcinoma |

|Metastatic adenocarcinoma |Metastatic adenocarcinoma (mostly from lower GI tract – intestinal type) |

|Metastatic adenocarcinoma of rectum |Secondary colorectal carcinoma |

|Metastatic adenocarcinoma probably from colorectal primary |Metastatic adenocarcinoma favouring colorectal origin |

|Metastatic carcinoma, likely from colorectal primary |Metastatic bowel adenocarcinoma |

|Metastatic large bowel adenocarcinoma |Metastatic adenocarcinoma, consistent with colo-rectal primary |

|Metastatic adenocarcinoma consistent with colorectal primary |Colonic metastatic adenocarcinoma deposit |

|Metastatic adenocarcinoma, primary colon |Metastatic colorectal carcinoma in adrenal gland |

|? metastatic adenocarcinoma +/- small cell/neuroendocrine element |Metastatic Adenocarcinoma from lower GI likely from previous Rectal |

|Adrenal gland – Metastasis of adenocarcinoma, intestinal type (GI tract to|Adenocarcinoma |

|investigate) |Metastatic adenocarcinoma of lower gastrointestinal origin |

|Metastatic adenocarcinoma, probably lower GI |Metastatic, lung adenocarcinoma (enteric variant) |

|Metastatic colorectal carcinoma to adrenal |Colorectal carcinoma metastasis |

|Metastatic adenocarcinoma from GI tract |Colorectal metastasis |

|Metastatic adenocarcinoma of colorectal origin | |

Reported Diagnosis: Metastatic Adenocarcinoma from colonic primary

EDUCATIONAL CASE

Case Number: 658 Click here to view digital image

Diagnostic category: Educational

Clinical : M80. Enlarged axillary and groin nodes. Ultrasound guided biopsy of left axillary node

Specimen : Lymph node core biopsy

Macro : Multiple cores of cream coloured tissue

Suggested diagnoses:

|Chronic lymphatic leukaemia |Lymph node – B-cell lymphoma (IHC needed) |

|Lymphoma |Hodgkin’s lymphoma – nodular lymphocytic predominant Hodgkin’s lymphoma |

|Castlemans disease |? Lymphoplasmacytic lymphoma (needs IHC for confirmation) |

|Lymphoplasmamcytic / lymphoplasmacytoid lymphoma |Lymphoplasmacytic lymphoma |

|Lymphocyte predominant Hodgkin’s lymphoma |Low grade lymphoma (needs immuno panel for subtype) |

|Hairy cell leukaemia |Myeloma |

|Non-Hodgkin’s Lymphoma |Plasmablastic lymphoma |

|Marginal zone lymphoma |Probably marginal zone lymphoma, needs IHC |

|B-cell lymphoma |Non Hodgkin’s Lymphoma probably mantle cell |

|Low grade NHL? LPL ? Marginal |Follicular B cell lymphoma |

|Low grade non Hodgkin lymphoma needs IHC |NHL ? CLL in transformation |

|Non-Hodgkin´s lymphoma –lymphoplasmacytic type |Dermatopathic. |

|Benign lymphadenopathy NOS |NH Lymphoma (possibly marginal zone with plasmacytic differentiation, but |

|Lymphoplasmacytic lymphoma |needs full IHC workup) |

|Malignant Lymphoma |Low grade B-NHL with plasmacytoid differentiation (?LPL)– needs immuno. |

|Low grade non-hodgekin lymphoma. ?CLL |Small round blue cell neoplasm possibly lymphoma – need immuno |

|Favour low grade lymphoma, requires immuopanel |NHL |

|Lymphoma, ? Hodgkin’s |Small lymphocytic lymphoma |

|Low grade non Hodgkin lymphoma favouring lymphoplasmacytic lymphoma |Non- Hodgkin’s lymphoma - ?Angio-immunoblastic T-cell NHL |

|?Lymphoplasmacytoid lymphoma |? Marginal zone lymphoma |

|Lymphoproliferative disorder, ? low grade lymphoma. IHC required. |? Hairy cell leukaemia infiltrate |

|Low grade lymphoma |Dermatopathic lymphadenopathy |

|Low grade NHL |Non-Hodgkin’s lymphoma. Referral required for typing. |

|? Lymphoma for further molecular/immunohistochemical testing |Lymphoplasmacytic Lymphoma |

|? Castleman’s disease |Malignant lymphoma, requires ICC |

|Low grade non-hodgkin lymphoma. ?marginal zone, ?LPL |Low grade non-Hodgkin lymphoma (mostly LPL) – IHC required |

|Hodgkins disease |Low grade diffuse lymphoma suggestive of SLL/CLL. Immunopanel to be done |

|Dermatopathic lymphadenopathy |for typing |

|Lymphoma ?T cell, |Low grade diffuse lymphoma suggestive of SLL/CLL. Immunopanel to be done |

|Metastatic melanoma |for typing |

|CLL type small cell lymphoma |Low grade B cell lymphoma |

|Lymphoplasmacytic lymphoma |Plasma cell neoplasm; further work up and clinical history required. |

|Marginal zone lymphoma |Castleman’s, plasma cell type |

|Plasmacytic lymphoma |Lymphoma (?nodular lymphocyte predominant Hodgkins) |

|Angioimmunoblastic T cell lymphoma |Nodular lymphocyte predominant Hodgkin’s Lymphoma |

|Hodgkin’s lymphoma lymphocytic predominant / Lymphoma Immunostaining for |Favour Castleman’s disease, plasma cell type. |

|confirmation |(dDx includes Mantle cell lymphoma, myeloma, autoimmune lymphadenitis) |

|B-Cell Non Hodgkin Lymphoma with plasmacytoid features.(immunos to |Low grade lymphoma, favouring marginal zone lymphoma |

|confirm) |Low grade Non Hodgkin Lymphoma-SLL/CLL |

|Lymphoma, differential between low grade B cell lymphoma with plasmacytic |Burkitt Lymphoma |

|differentiation and T cell angioimmunoblastic. Resort to IHC, history of |Nodular lymphocyte predominant lymphoma |

|?IgG paraproteins |Lymphocyte rich Hodgkin’s lymphoma |

|Nodular lymphocyte predominant Hodgkin’s lymphoma | |

|Mixed cellularity hodgkins lymphoma | |

|Plasmacytoma | |

Reported Diagnosis: Low grade B-Cell lymphoma of lymphoplasmacytic type.

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