Libre Pathology - User contributions [en]

Traditional adenoma

2013-07-29T14:39:27Z

Adnan: +VE Ki67

{{ Infobox diagnosis
| Name = {{PAGENAME}}
| Image = Tubular adenoma 4 high mag.jpg
| Width =
| Caption = Tubular adenoma. [[H&E stain]].
| Micro = nuclear changes - esp. at the surface (hyperchromatic elongated nuclei or round cleared nuclei), nuclear crowding/pseudostratification, +/- loss of nuclear polarity, loss/decrease of goblet cells, cytoplasmic hyperchromasia
| Subtypes = [[tubular adenoma]], [[villous adenoma]], [[tubulovillous adenoma]]
| LMDDx = [[sessile serrated adenoma]] with dysplasia, [[gastrointestinal polyps]]
| Stains =
| IHC =
| EM =
| Molecular =
| IF =
| Gross =
| Grossing =
| Site = usually rectum and distal large bowel
| Assdx = [[colorectal adenocarcinoma]]
| Syndromes = [[Familial adenomatous polyposis]]
| Clinicalhx =
| Signs = usually asymptomatic, may present with rectal bleeding
| Symptoms = uncommon, usually asymptomatic
| Prevalence = common
| Bloodwork = +/-anemia
| Rads = polyp
| Endoscopy = polyp - pedunculated or sessile
| Prognosis = good
| Other =
| ClinDDx = invasive [[colorectal adenocarcinoma]], benign colorectal mucosa, [[hyperplastic polyp]]
}}
{{ Infobox external links
| Name = {{PAGENAME}}
| EHVSC = 10192
| pathprotocols =
| wikipedia =
| pathoutlines =
}}

'''Traditional adenoma''' refers to a group of pre-[[cancer|cancerous]] lesions of the [[gastrointestinal pathology|gastrointestinal tract]].

It includes '''tubular adenoma''', '''tubulovillous adenoma''', and '''villous adenoma'''. These are abbreviated '''TA''', '''TVA''' and '''VA''' respectively.

==General==
*Most common group of ''adenomas'' in gastrointestinal tract.
*Usually arise in the context of an ''APC'' mutation.
*Many are seen in the context of [[familial adenomatous polyposis]].

==Gross==
*Polypoid mass or sessile mass.
**Villous adenoma sessile.

==Microscopic==
#Nuclear changes at the surface of the mucosa - '''key feature'''.
#*Size and shape ''or'' size change:
#**Cigar-shaped (elongated) nucleus (usu. length:width > 3:1) with nuclear hyperchromasia (more blue).
#**Large round nuclei +/- vesicular appearance (clearing) -- nuclei have white space.
#*Nuclear crowding/pseudostratification - '''important'''.
#*+/-Loss of nuclear polarity (nuclei no longer on basement membrane).
#Loss/decrease of goblet cells (common).
#Cytoplasmic hyperchromasia.

Notes:
*Nuclear changes deep to the surface are non-neoplastic if normal appearing mucosa (with small round nuclei) is superficial to it; mucosa that is more blue and atypical deep ''and'' less blue without nuclear atypia at the surface is said to be "maturing".
**Classically, adenomatous polyps have "reverse maturation":
***The surface is more hyperchromatic (more blue).
***The base is more mature (more globlet cells, no nuclear changes -- less blue).
*[[Ampullary adenoma]]s often have less prominent pseudostratification and fine chromatin.

===Images===
<gallery>
Image:Tubular_adenoma_4_low_mag.jpg| Small tubular adenoma - low mag. (WC/Nephron).
Image:Tubular_adenoma_4_high_mag.jpg| Small tubular adenoma - high mag. (WC/Nephron).
Image:Tubular_adenoma_2_intermed_mag.jpg| Tubular adenoma - intermed. mag. (WC/Nephron).
Image:Tubulovillous_adenoma.jpg| Tubulovillous adenoma (WC/Nephron).
</gallery>

www:
*[http://www.flickr.com/photos/jian-hua_qiao_md/3984353527/in/photostream/ TA (flickr.com)].
*[http://www.flickr.com/photos/jian-hua_qiao_md/3985116686/ TA with HGD (flickr.com)].
*[http://media.daveproject.org/media/images/pathology_img/fullsize/gsraju-flat_lession_emr-path.jpeg TA with HGD (daveproject.org)].<ref>URL: [http://daveproject.org/colon-cancer-prevention-flat-lesion-and-endoscopic-mucosal-resection/2011-06-10/ http://daveproject.org/colon-cancer-prevention-flat-lesion-and-endoscopic-mucosal-resection/2011-06-10/]. Accessed on: 24 August 2012.</ref>
*[http://www.diagnosticpathology.org/content/2/1/29/figure/f1?highres=y TA with HGD (diagnosticpathology.org)].<ref name=pmid17697327>{{Cite journal | last1 = Armah | first1 = HB. | last2 = Krasinskas | first2 = AM. | last3 = Parwani | first3 = AV. | title = Tubular adenoma with high-grade dysplasia in the ileal segment 34 years after augmentation ileocystoplasty: report of a first case. | journal = Diagn Pathol | volume = 2 | issue = | pages = 29 | month = | year = 2007 | doi = 10.1186/1746-1596-2-29 | PMID = 17697327 }}</ref>

====Typing====
Subclassified as:<ref name=pbod860>{{Ref PBoD|860}}</ref>
*''Tubular adenoma'' (most common), tubular component >75%.
*''Villous adenoma'' (least common ~= 1% of (traditional) adenomas), villous component >50%.
*''Tubulovillous adenoma'' (uncommon ~5-10% of (traditional) adenomas), villous component >=25% & <=50%.

In other words:
*Tubular T/V >75% / <25%; Tubulovillous T/V <=75%-50% / 25%-<50%; Villous T/V <=50% / >50%.

Note 1:<ref name=pbod860/>
*Most villous adenomas are sessile, i.e. flat.<ref name=emed_va>URL: [http://emedicine.medscape.com/article/170283-overview http://emedicine.medscape.com/article/170283-overview].</ref>
*Tubular adenomas tend to be pedunculated, i.e. have a stalk.
*Villous adenomas have a worse prognosis and warrant closer follow-up.
*One needs only to remember the criteria for ''tubular adenomas'' and ''villous adenomas'', as tubulovillous adenomas are what is left over.
**Tubular adenomas >75% tubular, Villous adenoma >=50% villous.
*Historically, there were different definitions for tubular adenoma, tubulovillous adenoma, and villous adenomas.<ref name=emed_va/>
**Health Organization (WHO) criteria: villous adenomas >80% villous architecture.

Note 2:
*There is no formal definition of "villous" architecture.<ref>R. Riddell. 12 August 2011.</ref>
**''[[Onlinepathology]]'' suggests: slender finger-like projections with length-to-width ratio greater than 4.

Note 3:
*The term ''tubular adenoma'' is used in different contexts; it should not be confused with [[Sertoli cell nodule]] ([[AKA]] ''testicular tubular adenoma'').

===Grading===
Adenomas are usually graded with a two-tier system:<ref name=driman>{{cite journal | last1 = Driman | first1 = DK. | last2 = Marcus | first2 = VA. | last3 = Hilsden | first3 = RJ | last4 = Owen | first4 = DA |title=Pathologic reporting of colorectal polyps: pan-Canadian consensus guidelines |journal=Canadian Journal of Pathology |volume=4 |issue=3 |pages=81-90 |year=2012 |month= |pmid= |doi= |url= }}</ref>

{| class="wikitable sortable"
!Feature
!Low grade dysplasia (LGD)
!High grade dysplasia (HGD)
!Importance
|-
|Architecture
|tubular, minimal focal gland fusion acceptable
|any of the following: (gland) cribriforming, glandular budding, intraluminal papillary tufting, sheeting (of epithelium), lamina propria invasion †
|'''key feature'''
|-
|Cytology
|usu. no features of HGD
|any of the following: loss of nuclear stratification, enlarged nuclei, loss of cell polarity, prominent nucleoli, open (clear) chromatin
|supportive feature, not sufficient alone for HGD
|}

Low power colour can be suggestive of HGD:
{| class="wikitable sortable"
!Feature
!Low grade
!High grade
|-
| Colour
| light blue
| dark blue
|}

Note:
*† In the colon, unlike other areas of the GI tract, invasive carcinoma is defined by neoplastic cells through the muscularis mucosae. In all other places, e.g. small bowel, invasive carcinoma is defined by neoplastic cells through the basement membrane.

===Margins===
{{Main|Surgical margins}}
*Some pathologists believe it is impossible to determine margins in polypectomies.
*Others comment on what they see and then disclaim based on limitations with something like "... margin clear in plane of section."

===Haggitt classification===
The ''Haggitt classification'' is a [[staging]] scheme. Surgeons may ask about it 'cause it appears in a widely read surgery textbook and is prognostic.
In short:<ref>URL: [http://www.ganfyd.org/index.php?title=Haggitt_classification http://www.ganfyd.org/index.php?title=Haggitt_classification]. Accessed on: 19 March 2011.</ref><ref name=pmid4007423>{{Cite journal | last1 = Haggitt | first1 = RC. | last2 = Glotzbach | first2 = RE. | last3 = Soffer | first3 = EE. | last4 = Wruble | first4 = LD. | title = Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. | journal = Gastroenterology | volume = 89 | issue = 2 | pages = 328-36 | month = Aug | year = 1985 | doi = | PMID = 4007423 }}</ref>
*0 - high-grade dysplasia. †
*1 - in submucosa but in head of polyp.
*2 - neck of polyp.
*3 - stalk of polyp.
*4 - submucosa of the bowel wall but above muscularis propria.
It is mostly useless; most polyps do not have a discernible neck or stalk.

Notes:
*† Some refer to this as "intramucosal carcinoma". This term is confusing in the context of colorectal lesions, as cancer is defined by submucosal invasion; it is probably best to avoid using this term.
*Dr. Haggitt is known for GI pathology and his tragic demise.<ref>Rodger C. Haggitt Endowed Chair in Gastroenterology. URL: [http://depts.washington.edu/givemed/prof-chair/endowments/rodger-haggitt/ http://depts.washington.edu/givemed/prof-chair/endowments/rodger-haggitt/]. Accessed on: February 2, 2013.</ref> He was shot by a resident that was about to be fired.<ref>Two die in UW medical school shooting. seattlepi.com. URL: [http://community.seattletimes.nwsource.com/archive/?date=20000629&slug=4029355 http://community.seattletimes.nwsource.com/archive/?date=20000629&slug=4029355]. Accessed on: 4 February 2013.</ref><ref>URL: [http://www.washington.edu/alumni/columns/sept00/choices.html http://www.washington.edu/alumni/columns/sept00/choices.html]. Accessed on: 4 February 2013.</ref>

==Sign out==
===Tubular adenoma - negative for high-grade===
<pre>
POLYP, SIGMOID COLON, EXCISION:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>

<pre>
POLYP, TRANSVERSE COLON, EXCISION:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>

===Tubulovillous adenoma - negative for high-grade===
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:
- TUBULOVILLOUS ADENOMA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>

===Villous adenoma - negative for high-grade===
<pre>
COLONIC POLYP, DESCENDING COLON, BIOPSY:
- VILLOUS ADENOMA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>

===Tubular adenoma with focal high-grade dysplasia===
<pre>
COLONIC POLYP, TRANSVERSE COLON, BIOPSY:
- TUBULAR ADENOMA WITH FOCAL HIGH-GRADE DYSPLASIA.
</pre>

===Tubular adenoma with high-grade dysplasia===
<pre>
COLONIC POLYP, SIGMOID COLON, BIOPSY:
- TUBULAR ADENOMA WITH HIGH-GRADE DYSPLASIA.
</pre>

===Invasion cannot be assessed===
<pre>
SIGMOID LESION, 25 CM, BIOPSY:
- TUBULAR ADENOMA.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA, SEE COMMENT.

COMMENT:
No stromal desmoplasia is identified. No definite submucosa is present; thus, the presence or absence of definite invasion cannot be assessed.
</pre>

===Fragment counting===
<pre>
COLONIC POLYP, TRANSVERSE COLON, BIOPSY:
- TUBULAR ADENOMA (IN 1/3 TISSUE FRAGMENTS).
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>

===Notes===
#"Negative for high-grade dysplasia and malignancy" is recommended in the Canadian consensus.<ref name=driman>{{cite journal | last1 = Driman | first1 = DK. | last2 = Marcus | first2 = VA. | last3 = Hilsden | first3 = RJ | last4 = Owen | first4 = DA |title=Pathologic reporting of colorectal polyps: pan-Canadian consensus guidelines |journal=Canadian Journal of Pathology |volume=4 |issue=3 |pages=81-90 |year=2012 |month= |pmid= |doi= |url= }}</ref> The reasoning for the first part is: "with low-grade dysplasia" may lead to over treatment by physicians that are not aware that all (traditional) adenomas have low-grade dysplasia.
#The phrase "negative for [...] malignancy" is also recommended in the Canadian consensus. This is not endorsed by [[onlinepathology]], as one very frequently does not get submucosa. It is like reporting "negative for muscularis propria invasion" on a urinary bladder biopsy without muscularis propria. Further, the guidelines are inconsistent in that they do not advise "negative for dysplasia and malignancy" for [[SSA]]s. If there is clinical suspicion of an invasive malignancy, it is useful to comment that no submucosa is present.

===Micro===
====Tubular-tubulovillous interface====
The sections shows colorectal-type mucosa with a tubule-forming epithelium that has cellular pseudostratification and enlarged hyperchromatic nuclei, from the crypt base to the luminal aspect (dysplasia).

No cribriforming of glands, epithelial budding or intraluminal papillary tufting is identified. Goblet cells are present in the dysplastic epithelium. Dysplastic nuclei have an ellipsoid-shape and basally stratified.

A small number of rare finger-like epithelial projections (villi) are noted; however these appear to comprise less than 20% of the sampled tissue. It is possible that the villous component is higher, due to sampling error; thus, this could represent a tubulovillous adenoma.

====Tubulovillous adenoma====
The sections shows colorectal-type mucosa with a tubule-forming and villous-forming epithelium that has cellular pseudostratification and enlarged hyperchromatic nuclei, from the crypt base to the luminal aspect (dysplasia).

No cribriforming of glands, epithelial budding or intraluminal papillary tufting is identified. Goblet cells are rare in the dysplastic epithelium. Dysplastic nuclei have an ellipsoid-shape and basally stratified.

The villous component is over 25% of the lesion but less than 50% of the lesion.

====Low-grade versus high-grade====
The sections shows colorectal-type mucosa with an epithelium that has cellular pseudostratification and enlarged hyperchromatic nuclei at the the luminal aspect (dysplasia).

The architecture is tubular and villous. The tubular component is predominant.

Focally, the nuclei are round and vesicular, and the glands do not have appreciable numbers of goblet cells. Occasionally, glands are fused and show moderate complexity. No desmoplastic response is evident. Benign fragments of submucosa are present.

==See also==
*[[Gastrointestinal polyps]].
*[[Gastrointestinal pathology]].

==References==
{{Reflist|2}}

[[Category:Gastrointestinal pathology]]

Basal cell carcinoma

2013-07-29T14:29:05Z

Adnan: fix number

{{ Infobox diagnosis
| Name = {{PAGENAME}}
| Image = Basal_cell_carcinoma_-_high_mag.jpg
| Width =
| Caption = Basal cell carcinoma. [[H&E stain]].
| Micro = "basaloid cells", nests with peripheral palisading of cells, artefactual clefting, myxoid stroma
| Subtypes = superficial pattern, nodular pattern, morpheaform (sclerosing) pattern, infiltrative pattern, fibroepitheliomatous pattern, infundibulocystic pattern, adenoidal pattern
| LMDDx = [[trichoepithelioma]], [[adenoid cystic carcinoma]], [[eccrine poroma]], reticulated [[seborrheic keratosis]] (for BCC, fibroepitheliomatous pattern), [[basaloid squamous cell carcinoma]], [[basosquamous carcinoma]]
| Stains =
| IHC =
| EM =
| Molecular =
| IF =
| Gross = pearly nodule with telangiectasias
| Grossing =
| Site = [[skin]]
| Assdx =
| Syndromes = [[Bazex syndrome]], [[nevoid basal cell carcinoma syndrome]], [[xeroderma pigmentosum]]
| Clinicalhx =
| Signs =
| Symptoms =
| Prevalence = very common
| Bloodwork =
| Rads =
| Endoscopy =
| Prognosis = good
| Other =
| ClinDDx = [[solar elastosis]] with ectatic [[blood vessel]]s
}}
{{ Infobox external links
| Name = {{PAGENAME}}
| EHVSC = 10187
| pathprotocols =
| wikipedia =
| pathoutlines =
}}
'''Basal cell carcinoma''', abbreviated ''BCC'', is an extremely common form of skin cancer.

==General==
*Very common.
*Sun exposed skin.
*Hair bearing area; tumour derived from hair follicle - a more appropriate name might be ''trichoblastic carcinoma''.<ref name=Ref_Derm389>{{Ref Derm|389}}</ref>
*Very rarely metastasizes:
**Dermatopathologists might see a couple in their career.
**There are only ~ 300 literature reports of metastatic BCC.<ref name=pmid16208438>{{Cite journal | last1 = Ting | first1 = PT. | last2 = Kasper | first2 = R. | last3 = Arlette | first3 = JP. | title = Metastatic basal cell carcinoma: report of two cases and literature review. | journal = J Cutan Med Surg | volume = 9 | issue = 1 | pages = 10-5 | month = Jan | year = 2005 | doi = 10.1007/s10227-005-0027-1 | PMID = 16208438 }}</ref>

===Clinical===
*Telangiectasias.
*Raised pearly nodule.

===As part of a syndrome===
*[[Nevoid basal cell carcinoma syndrome]] (NBCCS), AKA ''Gorlin syndrome''.
*[[Bazex syndrome]] (X-linked).<ref>URL: [http://emedicine.medscape.com/article/1101146-diagnosis http://emedicine.medscape.com/article/1101146-diagnosis]. Accessed on: 6 May 2010.</ref>
*[[Xeroderma pigmentosum]].

==Microscopic==
Features:<ref name=Ref_PBoD8_1180-1>{{Ref PBoD8|1180-1}}</ref><ref name=Ref_Derm390>{{Ref Derm|390}}</ref>
#Basaloid cells - similar in appearance to basal cells:
#*Moderate blue/grey cytoplasm.
#*Dark ovoid/ellipsoid nucleus with uniform chromatin.
#Palisading of cells at the edge of the cell nests.
#Artefactual separation of cells (forming the nests) from the underlying stroma - '''key feature'''.
#Surrounded by blue [[myxoid stroma|(myxoid) stroma]] - '''key feature'''.

May be present:<ref name=Ref_Derm390>{{Ref Derm|390}}</ref>
*[[Dystrophic calcification]] - possibly more aggressive behaviour.<ref name=pmid20489568>{{Cite journal | last1 = Slodkowska | first1 = EA. | last2 = Cribier | first2 = B. | last3 = Peltre | first3 = B. | last4 = Jones | first4 = DM. | last5 = Carlson | first5 = JA. | title = Calcifications associated with basal cell carcinoma: prevalence, characteristics, and correlations. | journal = Am J Dermatopathol | volume = 32 | issue = 6 | pages = 557-64 | month = Aug | year = 2010 | doi = 10.1097/DAD.0b013e3181ca65e2 | PMID = 20489568 }}</ref>
*[[Amyloid]].
*Inflammation.

Notes:
*Palisading = the long axes of the cells are alined and the axes are perpendicular to the interface between the (basaloid cell) nests and stroma.
*Key elements in a list: Artefactual clefting (of nests), Basaloid cells, Peripheral palisading, Myxoid stroma.
**Memory device ''PAM'': palisading, artefactual clefts, myxoid stroma.

DDx:
*[[Trichoepithelioma]] - no artefactual cleft.<ref name=Ref_PBoD8_1180-1>{{Ref PBoD8|1180-1}}</ref>
*[[Adenoid cystic carcinoma]] - no myxoid stroma, no peripheral palisading.
*[[Eccrine poroma]] - on palms & soles, BCC rarely found there.<ref>{{Ref DCHH|284}}</ref>
*Reticulated [[seborrheic keratosis]] - for BCC, fibroepitheliomatous pattern.
*[[Basaloid squamous cell carcinoma]] - [[AKA]] squamous cell carcinoma, basaloid variant.
*[[Basosquamous carcinoma]] - squamous cell carcinoma with basal cell carcinoma (a collision tumour).
*[[Solar elastosis]] with ectatic [[blood vessel]]s.

===Images===
<gallery>
Image:Basal_cell_carcinoma_-_2_-_intermed_mag.jpg | BCC - intermed. mag. (WC/Nephron)
Image:Basal_cell_carcinoma_-_high_mag.jpg | BCC - high mag. (WC/Nephron)
Image:Basal_cell_carcinoma_pathology.jpg | BCC - poor quality. (WC)
Image:Basal_cell_carcinoma_fibroepitheliomatous_pattern_-_very_low_mag.jpg | Fibroepithelioma of Pinkus. (WC/Nephron)
Image:SkinTumors-P6040209.JPG | Fibroepithelioma of Pinkus. (WC)
</gallery>
www:
*[http://missinglink.ucsf.edu/lm/DermatologyGlossary/img/Dermatology%20Glossary/Glossary%20Histo%20Images/basal_cell_carcinoma_high_power.jpg BCC (ucsf.edu)].<ref>URL: [http://missinglink.ucsf.edu/lm/DermatologyGlossary/basal_cell_carcinoma.html http://missinglink.ucsf.edu/lm/DermatologyGlossary/basal_cell_carcinoma.html]. Accessed on: 4 September 2011.</ref>
*[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?f=1&sort=0&s=20080802171910891 BCC with fibroepitheliomatous pattern / fibroepithelioma of Pinkus (surgicalpathologyatlas.com)].
*[http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=930934558 BCC with fibroepitheliomatous pattern (dermatlas.med.jhmi.edu)].

===Basal cell carcinoma subtypes/unique features===
*Many patterns exist.
*Recurrence higher in morpheaform (sclerosing), infiltrative, micronodular, and superficial patterns.<ref>Basal cell carcinoma. eMedicine. ''Prognosis'' section. URL: [http://emedicine.medscape.com/article/276624-overview http://emedicine.medscape.com/article/276624-overview]. Accessed on: 17 September 2011.</ref>
*DG says the prognosis is similar for all BCC subtypes, except for ''sclerosing'' pattern and ''infiltrative'' pattern.<ref>Ghazarian, Danny; 14 September 2011.</ref>

The subtypes:<ref name=Ref_Derm392-5>{{Ref Derm|392-5}}</ref>
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Pattern
! Key histologic feature
! Other histologic features
! Other
|-
| Superficial pattern
| connected to epidermis
|
|
|-
| Nodular pattern
| nodules
| partial detachment from epidermis
| subgroup ''micronodular'' = nests equal size ~ 0.2 mm dia., >=25% of lesion
|-
| Morpheaform (sclerosing) pattern
| stroma sclerosis
|
| often seen with ''infiltrative pattern'', DDx: desmoplastic trichoepithelioma<ref name=pmid22366669>{{Cite journal | last1 = Kirzhner | first1 = M. | last2 = Jakobiec | first2 = FA. | last3 = Borodic | first3 = G. | title = Desmoplastic trichoepithelioma: report of a unique periocular case. | journal = Ophthal Plast Reconstr Surg | volume = 28 | issue = 5 | pages = e121-3 | month = | year = | doi = 10.1097/IOP.0b013e318245535a | PMID = 22366669 }}
</ref>
|-
| Infiltrative pattern
| small irregular cell aggregates
|
| often also sclerosing or morpheaform
|-
| Fibroepitheliomatous pattern
| cords and columns of basaloid cells
| fibrous stroma
| name of pattern comes from ''fibroepithelioma of Pinkus''; DDx: reticulated [[seborrheic keratosis]]
|-
| Infundibulocystic pattern
| small keratocysts (keratin cysts)
| usu. small, often in cords
| usu. indolent
|-
| Adenoidal pattern
| cribriform / pseudoglandular arch.
| myxoid stroma, peripheral palisading
| DDx: [[adenoid cystic carcinoma]]
|-
|}

Unique features/differentiation:<ref name=Ref_Derm392-5>{{Ref Derm|392-5}}</ref>
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Differentiation / unique cell
! Key histologic feature
! Other histologic features
! Other
|-
| Pigmented cells
| '''any pattern''' can have pigmentation
| pigment may be in malignant cell
| DDx: collision lesion with [[melanocytic lesion]]
|-
| Squamous differentiation (metatypical BCC)
| pink cytoplasm, keratinization
|
| assoc. with ulceration/tumour recurrence
|-
| Eccrine differentiation
| focal duct formation
|
| very rare, DDx: BCC engulfing sweat ducts
|-
| Clear cells (Clear cell BCC)
| clear cytoplasm
|
| due to glycogen
|}

==IHC==
*CK5/6 +ve.
**Useful to assess [[margins]]... if very close.
*CD10 +ve.
*Actin +ve.

Squamous cell carcinoma versus basal cell carcinoma:
*BerEP4 +ve.
**SCC usually negative.<ref name=pmid19187107>{{Cite journal | last1 = Yu | first1 = L. | last2 = Galan | first2 = A. | last3 = McNiff | first3 = JM. | title = Caveats in BerEP4 staining to differentiate basal and squamous cell carcinoma. | journal = J Cutan Pathol | volume = 36 | issue = 10 | pages = 1074-176 | month = Oct | year = 2009 | doi = 10.1111/j.1600-0560.2008.01223.x | PMID = 19187107 }}</ref>
*EMA -ve.
**SCC usually positive.<ref name=pmid10971697>{{Cite journal | last1 = Beer | first1 = TW. | last2 = Shepherd | first2 = P. | last3 = Theaker | first3 = JM. | title = Ber EP4 and epithelial membrane antigen aid distinction of basal cell, squamous cell and basosquamous carcinomas of the skin. | journal = Histopathology | volume = 37 | issue = 3 | pages = 218-23 | month = Sep | year = 2000 | doi = | PMID = 10971697 }}</ref>
*SMA +ve.<ref>URL: [http://www.ihcworld.com/_newsletter/2004/2004-12_basal_cell_vs_squamous_v1.pdf http://www.ihcworld.com/_newsletter/2004/2004-12_basal_cell_vs_squamous_v1.pdf]. Accessed on: 19 December 2012.</ref>
**SCC usually negative.

==Sign-out==
<pre>
SKIN LESION, SHAVE BIOPSY WITH ELECTRODESICCATION AND CURETTAGE (EDC):
- BASAL CELL CARCINOMA, MARGIN STATUS ASSESSED CLINICALLY DURING EDC.
- EXTENSIVE SOLAR ELASTOSIS.
</pre>

<pre>
SKIN LESION, RIGHT EAR, EXCISION:
- BASAL CELL CARCINOMA.
- MARGINS NEGATIVE FOR BASAL CELL CARCINOMA.
- EXTENSIVE SOLAR ELASTOSIS.
</pre>

<pre>
SKIN LESION, RIGHT TEMPLE, RE-EXCISION:
- BASAL CELL CARCINOMA, NODULAR, MARGINS NEGATIVE.
- DERMAL SCAR.
- EXTENSIVE SOLAR ELASTOSIS.
</pre>

===Micro===
The sections show hair-bearing skin with nests of basaloid cells in the dermis. The basaloid nests have peripheral palisading of the nuclei, have numerous mitoses, and are surrounded by a myxoid stroma. The nests are well demarcated from the stroma and show focal clefting from the stroma. The margins are negative for basal cell carcinoma.

==See also==
*[[Dermatopathology]].
*[[Dermatologic neoplasms]].

==References==
{{Reflist|2}}

[[Category:Diagnosis]]
[[Category:Dermatopathology]]

Basal cell carcinoma

2013-07-29T14:23:07Z

Adnan: +VS

{{ Infobox diagnosis
| Name = {{PAGENAME}}
| Image = Basal_cell_carcinoma_-_high_mag.jpg
| Width =
| Caption = Basal cell carcinoma. [[H&E stain]].
| Micro = "basaloid cells", nests with peripheral palisading of cells, artefactual clefting, myxoid stroma
| Subtypes = superficial pattern, nodular pattern, morpheaform (sclerosing) pattern, infiltrative pattern, fibroepitheliomatous pattern, infundibulocystic pattern, adenoidal pattern
| LMDDx = [[trichoepithelioma]], [[adenoid cystic carcinoma]], [[eccrine poroma]], reticulated [[seborrheic keratosis]] (for BCC, fibroepitheliomatous pattern), [[basaloid squamous cell carcinoma]], [[basosquamous carcinoma]]
| Stains =
| IHC =
| EM =
| Molecular =
| IF =
| Gross = pearly nodule with telangiectasias
| Grossing =
| Site = [[skin]]
| Assdx =
| Syndromes = [[Bazex syndrome]], [[nevoid basal cell carcinoma syndrome]], [[xeroderma pigmentosum]]
| Clinicalhx =
| Signs =
| Symptoms =
| Prevalence = very common
| Bloodwork =
| Rads =
| Endoscopy =
| Prognosis = good
| Other =
| ClinDDx = [[solar elastosis]] with ectatic [[blood vessel]]s
}}
{{ Infobox external links
| Name = {{PAGENAME}}
| EHVSC = 10182
| pathprotocols =
| wikipedia =
| pathoutlines =
}}
'''Basal cell carcinoma''', abbreviated ''BCC'', is an extremely common form of skin cancer.

==General==
*Very common.
*Sun exposed skin.
*Hair bearing area; tumour derived from hair follicle - a more appropriate name might be ''trichoblastic carcinoma''.<ref name=Ref_Derm389>{{Ref Derm|389}}</ref>
*Very rarely metastasizes:
**Dermatopathologists might see a couple in their career.
**There are only ~ 300 literature reports of metastatic BCC.<ref name=pmid16208438>{{Cite journal | last1 = Ting | first1 = PT. | last2 = Kasper | first2 = R. | last3 = Arlette | first3 = JP. | title = Metastatic basal cell carcinoma: report of two cases and literature review. | journal = J Cutan Med Surg | volume = 9 | issue = 1 | pages = 10-5 | month = Jan | year = 2005 | doi = 10.1007/s10227-005-0027-1 | PMID = 16208438 }}</ref>

===Clinical===
*Telangiectasias.
*Raised pearly nodule.

===As part of a syndrome===
*[[Nevoid basal cell carcinoma syndrome]] (NBCCS), AKA ''Gorlin syndrome''.
*[[Bazex syndrome]] (X-linked).<ref>URL: [http://emedicine.medscape.com/article/1101146-diagnosis http://emedicine.medscape.com/article/1101146-diagnosis]. Accessed on: 6 May 2010.</ref>
*[[Xeroderma pigmentosum]].

==Microscopic==
Features:<ref name=Ref_PBoD8_1180-1>{{Ref PBoD8|1180-1}}</ref><ref name=Ref_Derm390>{{Ref Derm|390}}</ref>
#Basaloid cells - similar in appearance to basal cells:
#*Moderate blue/grey cytoplasm.
#*Dark ovoid/ellipsoid nucleus with uniform chromatin.
#Palisading of cells at the edge of the cell nests.
#Artefactual separation of cells (forming the nests) from the underlying stroma - '''key feature'''.
#Surrounded by blue [[myxoid stroma|(myxoid) stroma]] - '''key feature'''.

May be present:<ref name=Ref_Derm390>{{Ref Derm|390}}</ref>
*[[Dystrophic calcification]] - possibly more aggressive behaviour.<ref name=pmid20489568>{{Cite journal | last1 = Slodkowska | first1 = EA. | last2 = Cribier | first2 = B. | last3 = Peltre | first3 = B. | last4 = Jones | first4 = DM. | last5 = Carlson | first5 = JA. | title = Calcifications associated with basal cell carcinoma: prevalence, characteristics, and correlations. | journal = Am J Dermatopathol | volume = 32 | issue = 6 | pages = 557-64 | month = Aug | year = 2010 | doi = 10.1097/DAD.0b013e3181ca65e2 | PMID = 20489568 }}</ref>
*[[Amyloid]].
*Inflammation.

Notes:
*Palisading = the long axes of the cells are alined and the axes are perpendicular to the interface between the (basaloid cell) nests and stroma.
*Key elements in a list: Artefactual clefting (of nests), Basaloid cells, Peripheral palisading, Myxoid stroma.
**Memory device ''PAM'': palisading, artefactual clefts, myxoid stroma.

DDx:
*[[Trichoepithelioma]] - no artefactual cleft.<ref name=Ref_PBoD8_1180-1>{{Ref PBoD8|1180-1}}</ref>
*[[Adenoid cystic carcinoma]] - no myxoid stroma, no peripheral palisading.
*[[Eccrine poroma]] - on palms & soles, BCC rarely found there.<ref>{{Ref DCHH|284}}</ref>
*Reticulated [[seborrheic keratosis]] - for BCC, fibroepitheliomatous pattern.
*[[Basaloid squamous cell carcinoma]] - [[AKA]] squamous cell carcinoma, basaloid variant.
*[[Basosquamous carcinoma]] - squamous cell carcinoma with basal cell carcinoma (a collision tumour).
*[[Solar elastosis]] with ectatic [[blood vessel]]s.

===Images===
<gallery>
Image:Basal_cell_carcinoma_-_2_-_intermed_mag.jpg | BCC - intermed. mag. (WC/Nephron)
Image:Basal_cell_carcinoma_-_high_mag.jpg | BCC - high mag. (WC/Nephron)
Image:Basal_cell_carcinoma_pathology.jpg | BCC - poor quality. (WC)
Image:Basal_cell_carcinoma_fibroepitheliomatous_pattern_-_very_low_mag.jpg | Fibroepithelioma of Pinkus. (WC/Nephron)
Image:SkinTumors-P6040209.JPG | Fibroepithelioma of Pinkus. (WC)
</gallery>
www:
*[http://missinglink.ucsf.edu/lm/DermatologyGlossary/img/Dermatology%20Glossary/Glossary%20Histo%20Images/basal_cell_carcinoma_high_power.jpg BCC (ucsf.edu)].<ref>URL: [http://missinglink.ucsf.edu/lm/DermatologyGlossary/basal_cell_carcinoma.html http://missinglink.ucsf.edu/lm/DermatologyGlossary/basal_cell_carcinoma.html]. Accessed on: 4 September 2011.</ref>
*[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?f=1&sort=0&s=20080802171910891 BCC with fibroepitheliomatous pattern / fibroepithelioma of Pinkus (surgicalpathologyatlas.com)].
*[http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=930934558 BCC with fibroepitheliomatous pattern (dermatlas.med.jhmi.edu)].

===Basal cell carcinoma subtypes/unique features===
*Many patterns exist.
*Recurrence higher in morpheaform (sclerosing), infiltrative, micronodular, and superficial patterns.<ref>Basal cell carcinoma. eMedicine. ''Prognosis'' section. URL: [http://emedicine.medscape.com/article/276624-overview http://emedicine.medscape.com/article/276624-overview]. Accessed on: 17 September 2011.</ref>
*DG says the prognosis is similar for all BCC subtypes, except for ''sclerosing'' pattern and ''infiltrative'' pattern.<ref>Ghazarian, Danny; 14 September 2011.</ref>

The subtypes:<ref name=Ref_Derm392-5>{{Ref Derm|392-5}}</ref>
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Pattern
! Key histologic feature
! Other histologic features
! Other
|-
| Superficial pattern
| connected to epidermis
|
|
|-
| Nodular pattern
| nodules
| partial detachment from epidermis
| subgroup ''micronodular'' = nests equal size ~ 0.2 mm dia., >=25% of lesion
|-
| Morpheaform (sclerosing) pattern
| stroma sclerosis
|
| often seen with ''infiltrative pattern'', DDx: desmoplastic trichoepithelioma<ref name=pmid22366669>{{Cite journal | last1 = Kirzhner | first1 = M. | last2 = Jakobiec | first2 = FA. | last3 = Borodic | first3 = G. | title = Desmoplastic trichoepithelioma: report of a unique periocular case. | journal = Ophthal Plast Reconstr Surg | volume = 28 | issue = 5 | pages = e121-3 | month = | year = | doi = 10.1097/IOP.0b013e318245535a | PMID = 22366669 }}
</ref>
|-
| Infiltrative pattern
| small irregular cell aggregates
|
| often also sclerosing or morpheaform
|-
| Fibroepitheliomatous pattern
| cords and columns of basaloid cells
| fibrous stroma
| name of pattern comes from ''fibroepithelioma of Pinkus''; DDx: reticulated [[seborrheic keratosis]]
|-
| Infundibulocystic pattern
| small keratocysts (keratin cysts)
| usu. small, often in cords
| usu. indolent
|-
| Adenoidal pattern
| cribriform / pseudoglandular arch.
| myxoid stroma, peripheral palisading
| DDx: [[adenoid cystic carcinoma]]
|-
|}

Unique features/differentiation:<ref name=Ref_Derm392-5>{{Ref Derm|392-5}}</ref>
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Differentiation / unique cell
! Key histologic feature
! Other histologic features
! Other
|-
| Pigmented cells
| '''any pattern''' can have pigmentation
| pigment may be in malignant cell
| DDx: collision lesion with [[melanocytic lesion]]
|-
| Squamous differentiation (metatypical BCC)
| pink cytoplasm, keratinization
|
| assoc. with ulceration/tumour recurrence
|-
| Eccrine differentiation
| focal duct formation
|
| very rare, DDx: BCC engulfing sweat ducts
|-
| Clear cells (Clear cell BCC)
| clear cytoplasm
|
| due to glycogen
|}

==IHC==
*CK5/6 +ve.
**Useful to assess [[margins]]... if very close.
*CD10 +ve.
*Actin +ve.

Squamous cell carcinoma versus basal cell carcinoma:
*BerEP4 +ve.
**SCC usually negative.<ref name=pmid19187107>{{Cite journal | last1 = Yu | first1 = L. | last2 = Galan | first2 = A. | last3 = McNiff | first3 = JM. | title = Caveats in BerEP4 staining to differentiate basal and squamous cell carcinoma. | journal = J Cutan Pathol | volume = 36 | issue = 10 | pages = 1074-176 | month = Oct | year = 2009 | doi = 10.1111/j.1600-0560.2008.01223.x | PMID = 19187107 }}</ref>
*EMA -ve.
**SCC usually positive.<ref name=pmid10971697>{{Cite journal | last1 = Beer | first1 = TW. | last2 = Shepherd | first2 = P. | last3 = Theaker | first3 = JM. | title = Ber EP4 and epithelial membrane antigen aid distinction of basal cell, squamous cell and basosquamous carcinomas of the skin. | journal = Histopathology | volume = 37 | issue = 3 | pages = 218-23 | month = Sep | year = 2000 | doi = | PMID = 10971697 }}</ref>
*SMA +ve.<ref>URL: [http://www.ihcworld.com/_newsletter/2004/2004-12_basal_cell_vs_squamous_v1.pdf http://www.ihcworld.com/_newsletter/2004/2004-12_basal_cell_vs_squamous_v1.pdf]. Accessed on: 19 December 2012.</ref>
**SCC usually negative.

==Sign-out==
<pre>
SKIN LESION, SHAVE BIOPSY WITH ELECTRODESICCATION AND CURETTAGE (EDC):
- BASAL CELL CARCINOMA, MARGIN STATUS ASSESSED CLINICALLY DURING EDC.
- EXTENSIVE SOLAR ELASTOSIS.
</pre>

<pre>
SKIN LESION, RIGHT EAR, EXCISION:
- BASAL CELL CARCINOMA.
- MARGINS NEGATIVE FOR BASAL CELL CARCINOMA.
- EXTENSIVE SOLAR ELASTOSIS.
</pre>

<pre>
SKIN LESION, RIGHT TEMPLE, RE-EXCISION:
- BASAL CELL CARCINOMA, NODULAR, MARGINS NEGATIVE.
- DERMAL SCAR.
- EXTENSIVE SOLAR ELASTOSIS.
</pre>

===Micro===
The sections show hair-bearing skin with nests of basaloid cells in the dermis. The basaloid nests have peripheral palisading of the nuclei, have numerous mitoses, and are surrounded by a myxoid stroma. The nests are well demarcated from the stroma and show focal clefting from the stroma. The margins are negative for basal cell carcinoma.

==See also==
*[[Dermatopathology]].
*[[Dermatologic neoplasms]].

==References==
{{Reflist|2}}

[[Category:Diagnosis]]
[[Category:Dermatopathology]]

Help:How to edit

2013-07-25T16:06:03Z

Adnan: reverting previous

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[[Category:Onlinepathology]]

Help:How to edit

2013-07-25T16:05:33Z

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[[Category:Onlinepathology]]

Libre Pathology:Manual of style

2013-07-25T16:03:51Z

Adnan: first edit

This page is the [[onlinepathology]] '''manual of style'''. It describes the '''format''' of the onlinepathology.org, i.e. this web site.

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{{ Infobox diagnosis
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==Name of entity==
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==Microscopic (heading)==
*The key feature(s) should be marked.
**Definition: A key feature is a distinctive '''common''' feature that strongly favours the given diagnosis and whose absense would strongly disfavour the diagnosis ''or'' exclude it.
***Examples:
***#Eosinophils in eosinophilic esophagitis.
***#Nuclear atypia at the free surface in tubular adenoma.

==See also==
*[[Onlinepathology]].
*[[References]].

==External links==
*[http://en.wikipedia.org/wiki/Wikipedia:Manual_of_Style/Medicine-related_articles Wikipedia - Manual of style for medicine-related articles (wikipedia.org)].
*[http://en.wikipedia.org/wiki/Wikipedia:CHEAT Wikipedia Cheatsheet (wikipedia.org)].

[[Category:Onlinepathology]]