Transcript Unknown primary tumors

Unknown primary tumors :
common misdiagnosis
Oscar Nappi
UOSC di Anatomia patologica
AORN A. Cardarelli - Napoli
Shapira DV, Jarrett AR
The need to consider survival, otcome and expense when
evalueting and treating patients with unknown primary carcinoma
Arch Intern Med 155 : 2050-2054, 1995
• 56 pts with CUP
• The average cost to each patient for
clinical procedures was 17.973 dollars
• Only in 4 cases the primary tumor was
found
• None of the neoplasms was deemed curable
and less than 20% of the patients survived
more than 12 months after initiation of
therapy
Pathologist’s role in management of
unknown primary tumors
• Conventional cyto- histologic studies correlated
to clinical setting
• IMMUNOHISTOCHEMICAL STUDIES
• Molecular biomarkers
microRNAs
GEP ( gene expression profiling )
M 64 ys
Cerebral mass
Guarda il
citoplasma…per me è un
sarcoma epiteliode !
Questo è un
linfoma maligno
anaplastico
Ma..! Le cellule sono
incise e
macronucleolate. E se
fosse un carcinoma ?
Diagnosi finale
Neoplasia maligna, n.a.s.,
quadro compatibile con
carcinoma scarsamente
differenziato (origine ignota)
metastatico
Metastatic melanoma
S100
HMB45
Polygonal large cell tumor
Immunoistochemical algorytm
Unknown primary tumors
Common misdiagnosis
Unknown primary tumors
Dangerous misdiagnosis
• Not diagnosing a malignant lymphoma
• Not diagnosing an endocrine tumor
• Not diagnosing other neoplasias with a favorable
( or relatively favorable ) therapeutical approach
Some neoplasias with a favorable
( or relatively favorable ) therapeutical approach
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•
•
•
•
Breast
Prostate
Extragonadal germ cell
“Peritoneal carcinoma”
Others
CD45
Large cell B lymphoma
Cytokeratin expression in hematological neoplasms:
a tissue microarray study on 866 lymphoma and
leukemia cases
Adams H, Schmid P, et al
Pathol Res Pract 204 : 569- 573, 2008
0,4%
0,6%
O,7 %
0,7%
4%
26%
HD
B-LCL
Peripheral T cell Lymphoma
Myeloma
Small cell ymphoma
Mantle cell lymphoma
Case 1
Pazient : F ys 46
Clinics and imaging
favour a diagnosis of
meningioma
CK
CK7
CK 20
LCA
Mammaglobin
HER2
ER
IHC in distinguish SCC and AC in poorly
differentiated lung tumours
Type
TTF-1
p63
Napsin A
34betaH11
SCC
___
+++
___
ADENO
+++
___
+++
Clinical Case
• M
47 ys
• Multiple bone metastasis ( 2 vertebral bodies,
femur ) and multiple nodules in both lungs
• FNA CAT-guided of a peripheral lung nodule
Napsin A
TTF1
Clinical case
• Metastatic lung adenocarcinoma
Also positive in mesothelioma and in
so called Primary peritoneal carcinoma
Clinical case
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•
•
•
M 38 ys
Axillary lymphadenopathy, retroperitoneal mass
No other apparent neoplastic lesions found
A lymphadenectomy is performed
Clinical case
• Immunohistochemical study
pan CK
CK 7
CK 20
PSA
TTF-1
napsin A
villin
positive
positive
negative
negative
negative
negative
negative
Adenocarcinoma NOS
Clinical case
• CD 30
• PLAP
• OCT 4
+++
+++++
CD30
Germ cell tumor
Embryonal carcinoma
Clinical Case
• Male ys 63
• Multiple hepatic
nodules
• At a first preliminary
screening by CAT no
other neoplastic lesions
found
?
Case
Preliminary immunohistochemical study :
• CD45
NEGATIVO
• HMB45
NEGATIVO
• S-100
NEGATIVO
• VIMENTINA
NEGATIVA
• Pan CK
POSITIVA
TTF-1
Poorly differentiated adenocarcinoma
of the lung ?
CK7
NE Markers !!
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•
•
•
Chromogranin A
Synaptophisin
CD56
CD57
• Negative
• Weakly and Focal +
Ki67 > 15%
High grade NE large cell
carcinoma of the lung
CD56
Dangerous misdiagnosis
Metastatic mimicking primary tumors
• Lung
• Liver
• Ovary
• Thyroid
• Breast
• Any organ
METASTASI ENDOBRONCHIALI:
QUADRI RADIOLOGICI INDISTINGUIBILI DALLA NEOPLASIA POLMONARE PRIMITIVA
Ca sigma
Ca stomaco
METASTASI A LOCALIZZAZIONE ENDOBRONCHIALE DA TUMORI EXTRA-POLMONARI: STUDIO EPIDEMIOLOGICO E CLINICO-PATOLOGICO
Grazie