24 September 2021: Weekly Roundup #65

This is what’s new on PathologyOutlines.com:

1. CAP 2021

Visit us at CAP ’21 this Sunday to Tuesday, Booth #214.

2. New Editorial Board Member for Pancreas Pathology

Dr. Wei Chen was appointed to our Editorial Board for Pancreas Pathology. Dr. Chen is an Associate Professor of Pathology and Director of Hepato-Pancreato-Biliary Pathology at The Ohio State University Wexner Medical Center in Columbus, Ohio. She obtained her M.D. at Peking University Health Science Center in Beijing, China. After earning a Ph.D. at Oregon State University in Corvallis, she completed a Pathology residency and a GI/Liver Pathology fellowship at The Ohio State University. Dr. Chen’s research focuses on pancreaticobiliary / liver pathology, Lynch syndrome and computer aided diagnostics.

3. Focus Groups

Are you interested in participating in industry focus groups, typically with an honorarium? Sign up for our Directory at https://www.pathologyoutlines.com/directorysignup.html and answer “Y” for the focus group question. Also, all who register for the Directory by October 31, 2021 are entered into our drawing for $50 and $100 gift cards.

4. What’s New in Pathology Newsletter

Our next What’s New in Pathology newsletter is on Molecular Pathology. Sign up to receive it at https://www.pathologyoutlines.com/subscribe.html.

5. Case of the Month #507

Case #507 was posted on September 16. You can sign up for our monthly case newsletters and more at https://www.pathologyoutlines.com/subscribe.html.

23 September 2021: Textbook Updates

We have posted updates of the following topics:

Adrenal gland & paraganglia > Other tumors > Adenomatoid tumor
by Katherine A. Lehman, B.S., Debra L. Zynger, M.D.
Topic summary: Rare benign nonfunctioning tumor of the adrenal gland of mesothelial origin. Proliferation of gland-like or vascular-like spaces lined by attenuated to columnar mesothelial cells. Epidemiology: age range 30 – 50 years, with peak incidence ~40 years. Thought to arise via entrapment of primitive mesenchymal cells from the Müllerian tract within the adrenal gland versus embolized mesothelial cells. Typically asymptomatic and discovered incidentally. Surgical excision or core biopsy with subsequent histopathologic evaluation necessary for diagnosis. Favorable prognosis, with no reported cases of recurrence following excision. Treatment: complete surgical resection.

Kidney nontumor > Glomerular disease > Infectious glomerulonephritis > Bacterial infection related GN
by Zhengchun Lu, M.D., Ph.D., Vanderlene Liu Kung, M.D., Ph.D.
Topic summary: Most common bacterial infection related glomerulonephritides in countries with higher human development indices are IgA dominant infection related glomerulonephritis and infectious endocarditis associated glomerulonephritis. Most common infectious agent is Staphylococcus aureus. Immune reaction to bacterial proteins, including bacterial superantigens, such as staphylococcal enterotoxins, ultimately result in immune complex deposition in glomeruli, inflammation, complement activation and glomerular injury. Diabetes and advanced age portend a worse prognosis. Primary treatment is antibiotic therapy targeting underlying infection.

Kidney tumor > Benign adult tumors > Hemangioma
by Bitania Wondimu, M.D., Maria Tretiakova, M.D., Ph.D.
Topic summary: Benign vascular proliferation, rarely diagnosed in kidney (more common in skin or superficial soft tissue). M:F = 1.8:1. Often associated with end stage renal disease; can be associated with acquired cystic kidney disease, polycythemia or renal cell carcinoma. Typically asymptomatic but can present with hematuria or flank / abdominal pain. Difficult to distinguish radiographically from malignant lesions; biopsy or excision often needed for definitive diagnosis. Excellent prognosis with excision. May regress spontaneously.

Pancreas > Acinar cell lesions > Acinar cell carcinoma
by Claudio Luchini, M.D., Ph.D.
Topic summary: Malignant exocrine neoplasm of the pancreas composed of cells with morphological resemblance to acinar cells and with immunohistochemistry positive for acinar markers. M:F = 2.1:1; average age: 60 years. Pathophysiology: accumulation of genetic alteration, including chromosomal instability and frequent allelic copy number variation. The prognosis is poor, with an average survival time of about 19 months. Treatment: surgical resection if possible, gemcitabine based chemotherapy / radiofrequency ablation, molecularly based target therapy in the case of actionable alterations.

22 September 2021: Pathologists’ Directory Highlights

If you are a pathologist, your colleagues will soon be looking you up regularly on our new Worldwide Directory of Pathologists because they saw your name connected with a surgical pathology report, a topic on our website, a paper, a talk, a committee or otherwise. If you have not yet signed up for the Directory, please click here and fill out our short survey to do so. If you’ve already signed up, please spread the word to your colleagues who have not signed up. Email Dr. Pernick at Nat@PathologyOutlines.com with any questions.

This week we are highlighting image contributions of pathologists from Northwestern University, in the Directory and otherwise.

Words of Wisdom

My mentor in residency (Dr. KarMing Fung) told me to remember these rules when I want to make a diagnosis: 1. Trust no one. 2. Find the killer. 3. Learn from others’ mistakes. (Courtesy of Sepideh Nikki Asadbeigi, M.D.)


Brain – Chordoid glioma (Courtesy of Daniel J. Brat, M.D., Ph.D.)

21 September 2021: Image Quiz #65

Author: Pablo Zoroquiain, M.D.

What finding in this sample is characteristic of pterygium?

Select an answer:

A. Bowman’s layer fragmentation

B. Elastosis of the lamina propria with corneal invasion

C. Epithelial atrophy with goblet cell loss

D. Neovascularization of the stroma

To sign up for our biweekly image quiz newsletters and more, visit pathologyoutlines.com/subscribe.html.

20 September 2021: Textbook Updates

We have posted updates of the following topics:

Bladder, ureter & renal pelvis > Other nonneoplastic > Prostatic type polyp
by Bonnie Choy, M.D.
Topic summary: Uncommon, nonneoplastic urothelial tract polyp comprised of prostatic glands and stroma. Polypoid or papillary lesion consists of nonneoplastic prostatic glandular epithelium with 2 distinct cell layers (luminal / secretory layer and basal layer) and corpora amylacea. Broad age range: 19 – 89 years. Most common in prostatic urethra, often in and around verumontanum. Diagnosis: cystoscopy with biopsy or transurethral resection. Low potential for recurrence. Simple resection is often curative.

Fallopian tubes & broad ligament > Broad ligament > Paratubal cysts
by Stephanie L. Skala, M.D.
Topic summary: Fluid filled cyst with ciliated lining adjacent to fallopian tube. Almost always benign, with rare reports of borderline tumor. Typically noted incidentally on intraoperative or gross examination (found in ~7 – 10% of women). Believed to originate from mesothelium or be remnant of Müllerian duct or Wolffian duct. Most cysts are small and asymptomatic (< 1 to 8 cm; rarely, 20+ cm). While not often diagnosed on imaging, paratubal cysts are unilocular and anechoic or hypoechoic on ultrasound. Rarely gives rise to serous borderline tumor or even more rarely malignancy. Surgical excision of the paratubal cyst represents definitive treatment for symptomatic patients.

Small intestine & ampulla > Congenital anomalies > Meckel diverticulum
by Yongchao Li, M.D., Ph.D., Lizhi Zhang, M.D.
Topic summary: Meckel diverticulum (MD) is a congenital disorder caused by incomplete obliteration of omphalomesenteric duct, which results in a true diverticulum, typically located in the ileum within 2 feet from the ileocecal valve. Most common congenital malformation of the GI tract, affecting 2 – 4% of the population. 16% of patients may be symptomatic; among symptomatic patients, M:F ≈ 3:1. Asymptomatic Meckel diverticulum is often incidentally diagnosed during laparoscopy or laparotomy. Treatment for symptomatic Meckel diverticulum is surgical resection.

Soft tissue > Adipose tissue tumors > Lipoma and variants > Spindle cell / pleomorphic lipoma
by Laura Warmke, M.D., Jeanne Meis, M.D.
Topic summary: Benign adipocytic tumors, currently regarded as morphologic variants of a single neoplasm. Spindle cell lipoma contains a varying mixture of mature adipocytes, bland spindle cells and ropy collagen fibers; pleomorphic lipoma also contains pleomorphic and multinucleated floret-like giant cells. Commonly affects middle aged to elderly men (45 – 70 years). Characterized by partial or whole chromosome 13 or 16 deletions. Demonstration of CD34 positivity and loss of RB1 helpful for diagnosis. Benign lesion, no risk of metastasis. Conservative surgical excision only.

Stains & CD markers > p53
by Till Braunschweig, M.D.
Topic summary: Tumor suppressor gene at 17p13, 53 kDa. Strong nuclear positivity or complete absence by immunohistochemistry has a strong correlation with the presence of a mutation. Women: almost 100% develop TP53 mutation associated cancer with a risk of 49% by the age of 30. Men: 79% develop TP53 mutation associated cancer with a risk of 21% by the age of 30. Interpretation: wildtype (normal) – scattered nuclear staining, mid epithelial (basal sparing). Poor outcome in p53 aberrant hematopoetic malignancies. Mostly missense or nonsense mutations, loss of function or splicing mutations uncommon.

17 September 2021: Weekly Roundup #64

This is what’s new on PathologyOutlines.com:

1. New Editorial Board Member for Hematopathology

Dr. Alexa Siddon was appointed to our Editorial Board for Hematopathology. Dr. Siddon is an Associate Professor of Laboratory Medicine and Pathology at Yale University School of Medicine. She is a hematopathologist, as well as the Medical Director for the Molecular Pathology Laboratory, Associate Director of Flow Cytometry, Associate Director of Hematology and the Hematopathology Fellowship Director. She obtained her M.D. at the State University of New York Upstate Medical University and then completed her AP/CP residency and Pathology Fellowship at Yale, where she has been practicing since.

2. Worldwide Directory of Pathologists Leaders

The current leaders for Directory signups as of September 15 are: Emory (26), MD Anderson (15), Northwestern (11), Ohio State, University of Florida, University of Michigan, University of Rochester (9), Harvard, University of Chicago (8), Mayo Clinic (7)

Make sure you’ve signed up for our directory here so that pathologists can find out more about you. Your PathOut webpage will remain stable even as your career changes. We suggest you also add this webpage to your email signature.

3. Top Topics on PathologyOutlines.com

We have updated the Top 150 Topics for the first half of 2021 on our Statistics page (also in the header or footer). The top 10 are:

4. Pathology Job Market

See Dr. Pernick’s comments on the Pathologist job market here.

5. Jobs Page

Currently, Jobs filtered for a subspecialty are sorted by location, as opposed to date posted. Which do you prefer? Email Nat@PathologyOutlines.com.

16 September 2021: Textbook Updates

We have posted updates of the following topics:

Breast > Ductal carcinoma in situ > Paget disease
by Jasmine Vickery, M.D., Anna Biernacka, M.D., Ph.D.
Topic summary: Mammary Paget disease (MPD) is a proliferation of malignant glandular epithelial cells (in situ carcinoma) in the nipple areolar epidermis. Cutaneous manifestation is due to tumor cells involving the epidermis and disrupting intercellular junctions. Relatively uncommon; occurs in 1 – 4% of women and 1 – 2% of men with breast cancer. In symptomatic cases, the diagnosis is primarily clinical and confirmed by histologic examination. Prognosis largely depends on the presence, extent and characteristics of the underlying tumor. Extent of surgery is determined by the extent of underlying breast carcinoma. Patients with limited disease are candidates for breast conserving therapy with central lumpectomy and whole breast irradiation.

Bone marrow neoplastic > Bone marrow – plasma cell and lymphoid neoplasms > Plasma cell neoplasms > MGUS-IgM
by Shuchi Zinzuwadia, B.S., Shweta S. Zinzuwadia, B.S., Maryam F. Raouf, M.D., Rita Gupta, M.D., Ameet R. Kini, M.D., Ph.D.
Topic summary: IgM monoclonal gammopathy of undetermined significance (MGUS) is characterized by < 3 g/dL of monoclonal IgM protein, < 10% clonal. Bone marrow clonal lymphoplasmacytic cells or clonal plasma cells < 10% of cellular elements. Prevalence of MGUS is 2 – 3% of adults over 50 years. Diagnosis of IgM MGUS is based on the presence of a serum IgM monoclonal protein < 3 g/dL, fewer than 10% clonal lymphoplasmacytic or plasma cells in the bone marrow and lack of evidence of progression to lymphoplasmacytic lymphoma / Waldenström macroglobulinemia, IgM multiple myeloma or AL amyloidosis. Risk factors for progression are initial concentration of the monoclonal protein (≥ 1.5 g/dL) and abnormal serum free light chain ratio. Treatment is not recommended for asymptomatic patients with IgM MGU; “Wait and watch” approach is usually followed.

Bone & joints > Notochordal lesions > Chordoma
by Jesse Hart, D.O.
Topic summary: Malignant tumor with notochordal differentiation. Typically involves the clivus, sacrococcygeal bones or vertebrae. Most commonly arises in the 40 – 60 year old age group (may occur at any age). Most cases are sporadic but rare cases may be associated with benign notochordal tumor. Diagnosis is based on morphology, immunohistochemical findings and anatomic location of the tumor. Median survival is 7 years; 5 year overall and disease free survival are 61% and 71%; 10 year overall and disease free survival are 41% and 57%. Treatment: usually surgery followed by radiation or radiation alone in poor surgical candidates; poor response to chemotherapy.

CNS nontumor > Toxic and metabolic disorders > Hepatic encephalopathy
by Palgun Nisarga, M.D., Kymberly A. Gyure, M.D.
Topic summary: Spectrum of neurocognitive abnormalities occurring in patients with acute or chronic liver disease or portosystemic shunting. Elevated blood ammonia levels considered to play central role. Epidemiology: chronic alcoholism, acute drug poisoning, status post portosystemic bypass, hepatic failure patients. Acute hepatic encephalopathy: cerebral edema and increased intracranial pressure (cause of death). Prognosis based on percent of viable hepatic parenchyma in acute hepatic failure. Treatment of precipitating event; reduce blood. ammonia concentration using nonabsorbable disaccharides or antibiotics

Soft tissue > Uncertain differentiation > Synovial sarcoma
by Farres Obeidin, M.D., Borislav A. Alexiev, M.D.
Topic summary: Malignant soft tissue tumor of uncertain histogenesis with variable epithelial differentiation. Can occur in or around any tissue in the body. Accounts for 5 – 10% of all soft tissue sarcomas; median age: 35. Etiology: despite the name, the cells of origin are not synovial cells; histogenesis is still debated. Biopsy is required for definitive diagnosis. Radiotherapy and adjuvant chemotherapy have been evaluated in high risk situations (tumors > 5 cm or difficult to resect).

15 September 2021: Pathologists’ Directory Highlights

If you are a pathologist, your colleagues will soon be looking you up regularly on our new Worldwide Directory of Pathologists because they saw your name connected with a surgical pathology report, a topic on our website, a paper, a talk, a committee or otherwise. If you have not yet signed up for the Directory, please click here and fill out our short survey to do so. If you’ve already signed up, please spread the word to your colleagues who have not signed up. Email Dr. Pernick at Nat@PathologyOutlines.com with any questions.

This week we are highlighting image contributions of our Breast Pathology Deputy Editor and Editorial Board members, in the Directory and otherwise.

Favorite Images

Breast perilobular hemangioma (bird) (Courtesy of Julie M. Jorns, M.D.)

Benign breast duct (Courtesy of Kristen E. Muller, D.O.)

PDL1 SP142: positive (IC: 5%), expression observed in both immune cell (lower right) and tumor cell component (upper left). Immune cell staining is punctate and granular. Tumor cell staining pattern is linear, circumferential.(Courtesy of Gary Tozbikian, M.D.)

14 September 2021: Pandemic Relief Music Award – September Winner

PathologyOutlines.com celebrated 20 years of operation in August 2021 and wants to give back to some of those suffering during the COVID-19 pandemic. For 2021, we will be promoting select classical and jazz musicians each month on our website and with a cash stipend. Recipients of this award will be posted each month and will remain visible on the website throughout the year.

The September Recipient for this award is Em and Em Duo.

Em & Em

Em & Em is an acoustic duo that performs a large variety of styles including jazz, folk and pop. Emilio and Emma met during their undergrad at Cal State Long Beach. Since forming Em & Em Duo in 2016, they’ve performed at many venues around Los Angeles and Orange County. They released their first acoustic album of originals, “Take Our Time,” in 2019 and released their second album, “You Are,” with a full band in May of 2021. They believe in playing and writing music that moves them, and sending a message of strong community relationships. 

The last year has brought a lot of change for both of them with Emma moving to Michigan to start a graduate degree in jazz voice at Western Michigan University, and Emilio starting a family in LA. They continue to compose and collaborate together from across the country, including their 2021 album that was recorded and produced completely remotely. 

In order to apply for a pandemic relief music award:

  1. The musician / ensemble must be based in the United States of America or Canada.
  2. The musician / ensemble must provide a media sample.
  3. The musician / ensemble must have a website or Facebook page that can be linked to.
  4. The musician / ensemble must have at least 2 or more audio / video recordings available via audio CD, online playlist, etc.

More information about the award, including application information, can be found on our website.

13 September 2021: Textbook Updates

We have posted updates of the following topics:

Eye > Conjunctiva > Epithelial tumors > Squamous papilloma-conjunctiva
by Pablo Zoroquiain, M.D.
Topic summary: Benign tumor characterized by an outgrowth of epithelial and stromal elements of the conjunctiva. Strong association with human papillomavirus (HPV 6 and 11). Approximately 1% of epibulbar cases in children and 11% in adults. Human papillomavirus 6 and 11 (low risk subtype) in nonlimbal papilloma. Diagnosis performed under ophthalmologic examination; slit lamp observation usually aids in the differential diagnosis. High recurrence rate: younger patients > older patients. Observation and follow up can be used, as some of these lesions regress. Medical treatment includes cryotherapy, CO2 laser, mitomycin C, cimetidine and interferon.

Informatics, digital & computational pathology > Digital imaging > Digital imaging fundamentals & standards
by Snehal S. Sonawane, M.B.B.S., M.D., Dariusz Borys, M.D.
Topic summary: Dynamic, image based environment that enables the acquisition, management and interpretation of pathology information generated from a digitized glass slide. Glass slides are converted into digital images with the aid of specialized scanning machines; slides can then be viewed, managed, shared and analyzed utilizing computer based technology. Facilitates flexibility and remote working. Applications include frozen section diagnosis in remote areas, primary diagnosis of pathology specimens in clinical use, assessment of immunohistochemistry and in situ hybridization. Limitations: expensive, unstable technology (possibility of network, software and hardware failure), difficult to define a standard for pathology images due to various imaging and nonimaging parameters.

Pancreas > Cystic and intraductal lesions > Intraductal papillary mucinous neoplasm
by Diana Agostini-Vulaj, D.O.
Topic summary: Intraductal papillary mucinous neoplasm (IPMN) is a grossly visible noninvasive mucinous epithelial neoplasm arising from main pancreatic duct or branch ducts, usually > 5 mm, composed of various cell types with various cytologic and architectural atypia. Rising incidence likely secondary to better characterization of this entity along with use of radiologic imaging studies. No well established factors; cigarette smoking implicated in one series. Clinically divided into main duct IPMN, branch duct IPMN and mixed IPMN. Without an invasive carcinoma, has > 90% 5 year survival; those associated with an invasive carcinoma carry a worse prognosis (about half die of the disease). Main duct IPMN: surgical resection indicated if main pancreatic duct > 10 mm, jaundice or presence of mural nodules.

Placenta > Nonneoplastic placental conditions and abnormalities > Noninfectious > Chorangiosis
by Anh Huynh, M.D., Drucilla J. Roberts, M.D.
Topic summary: Capillary hyperplasia in terminal villi due to chronic placental hypoperfusion or low grade tissue hypoxia.Higher incidence in maternal pathological conditions associated with hypoxemia. May be seen in pregnancies complicated by preeclampsia, diabetes mellitus, high altitudes, anemia, certain infections, multiple gestations, cardiovascular or respiratory disease, air pollution, obesity and tobacco smoking. Altshuler criteria: > 10 capillaries in at least 10 terminal villi in ≥ 10 noninfarcted areas in at least 3 low power fields of the placenta. Focal and diffuse chorangiosis have similar prognostic features.