Immunohistochemical Stains

internalchildlikeInternet and Web Development

Nov 12, 2013 (3 years and 11 months ago)

75 views

Case Report


2008.11.27


Presentation: R1
陳坤翰

Supervisor: Chief
陳肇真

History



X



13Y6M boy



Chief complaint:


R’t neck mass(4x4cm, firm, fixed) for 3
wks

Clinical Course

LMD*3


Infectious
lymphadenopathy


Antibiotics treatment



No improved

9/20

10/14

NCKUH Dr.
陳建旭

No fever, URI S/S and B Symptoms

WBC: 6.4K, Seg: 44%, Lym: 44%

Hb:14.4, CRP: 11.5

Head CT:


Multiple enlarged lymph
nodes

at Bil. upper
parajugular and R’t posterior
cervical spaces.

Suspicious lymphoma

10/15

10/16

Neck mass biopsy and
Port
-
A implantation

Frozen: Atypical cell

CT on 2008/10/15

CT on 2008/10/15


Multiple enlarged lymph nodes

at Bil. upper
parajugular and R’t posterior cervical
spaces.
Suspicious lymphoma
.


Soft tissue mass lesion in the R’t
nasopharynx.
(
更正重發
)



R’t sphenoid sinusitis.

Clinical Course

10/17

Pathology
Telephone


Malignancy

CK(
-
), CD30(+)



Lymphoma

10/20

AFP& HCG: WNL

Bone marrow biopsy and
aspiration: No evidence of
malignancy and metastasis

19:20: Pathology Telephone:
NPC

10/21

Epistaxis x2

EB VCA IgM Ab:
1:10(
-
)

EB VCA IgG Ab:
1:40(+)

10/22

Naso
-
endoscopic
biopsy

Bone scan: no
obvious bone
metastasis

10/24

MRI:

Bil. NPC with bony invasion and
metastatic lymph nodes at R’t
level II


Definite diagnosis of pathology:
NPC

10/25

Discharge

for
CCRT in
柳營
奇美

H.

MRI on 2008/10/24

MRI on 2008/10/24


Consider bil. NPC with


Superior extension to
R’t
cavernous sinus


Bony invasion to clivus and
petrous apex of
R’t
temporal bone
.


Invasion to
sphenoid sinus

with destruction of
sphenoid sinus floor


Suspect
metastatic lymph
nodes

at
R’t level II


Pathology

Micro
-
Lower Power Field


Germinal center


Tumor cell in sinusoid


Micro
-
High Power Field


Polygonal


Large nuclei


Carcinoma
metastasis


Diffuse large B
lymphoma


Anaplastic large
cell lymphoma


Horgkin lymphoma

Immunohistochemical Stains


Cytokeratin: (+)


Favored
Carcinoma

20081031

Immunohistochemical Stains


CD30(+)


Anaplastic large
cell lymphoma


Horgkin
lymphoma


Germ cell tumor


NPC: 30%(+)

Immunohistochemical Stains


Leukocyte
common
antigen
(LCA):
(
-
)


Lymphocyte

Immunohistochemical Stains


EBV
-
encoded
RNA(EBER): (+)


Favored
NPC

20081031

Micro
-
Lower Power Field


Naso
-
endoscopic biopsy

Micro
-
High Power Field


Naso
-
endoscopic biopsy


Polymorphous


Large nuclei

Immunohistochemical Stains


Naso
-
endoscopic biopsy


EBV
-
encoded
RNA(EBER): (+)


Favored
NPC

Diagnosis

Nasopharyngeal carcinoma

T4N2M0, Stage IVa

Epidemiology


Endemic in southern China



25
-
50/100,000 per year(50 times to western)


Male (2
-
3.5 :1)


Age: 20
-
60 year
-
old (<18yr: 5
-
6% in all NPC)


Risk factors


Diet: nitrates (4.6X)


Epstein
-
Barr virus (EBV)


Genetic predisposition (First degree NPC: 7.6X)

Type


Keratinizing squamous cell carcinoma (WHO type I)


75% in USA


Cigarette smoking and alcohol consumption



Non
-
keratinizing carcinoma (WHO type II)


Lymphoepithelioma: infiltration of benign T
-
lymphocytes


EBV: strongly association


Radiosensitive: relative good prognosis


5
-
yr survival rate: 60%


Undifferentiated carcinoma (WHO type III)


Childhood and adolescence



World Heath Organization Classification of Tumors: Pathology and Genetics: Head and Neck Tumors.
Barnes, L, Everson, JW, Reichart, P, Sidransky, D. (Eds). WHO Press, Switzerland 2005


S/S:


Headache


Neck mass
75
-
90%, 50% in bilateral


Nasal obstruction with epistaxis


Otitis media


Metastasis:
5
-
11% initial diagnosis


Bone (skull base, cranial nerves

)
70
-
80% of metastasis



Lung


Liver

Fan, SQ, Ma, J, Zhou, J, et al. Differential expression of Epstein
-
Barr virus
-
encoded RNA and several tumor
-
related
genes in various types of nasopharyngeal epithelial lesions and nasopharyngeal carcinoma using tissue microarray
analysis. Hum Pathol 2006; 37:593.

Altun, M, Fandi, A, Dupuis, O, et al. Undifferentiated nasopharyngeal cancer (UCNT): current diagnostic and
therapeutic aspects. Int J Radiat Oncol Biol Phys 1995; 32:859.

Early Detection


Anti
-
EBV serologic profile


Viral capsid antigen (VCA) IgG antibodies


Viral capsid antigen (VCA) IgM antibodies


Early antigen (EA) antibodies


EBNA IgG antibodies: Chronic



EBV DNA PCR for Recurrence


Nasopharyngeal brush biopsy


PCR to identify EBV DNA


Ji, MF, Wang, DK, Yu, YL, et al. Sustained elevation of Epstein
-
Barr virus antibody levels preceding
clinical onset of nasopharyngeal carcinoma. Br J Cancer 2007; 96:623.

Treatment and Prognosis


Early stage (T1
-
2N0
-
1): Radiotherapy


Advanced NPC (T3
-
4orN2
-
3): CCRT

Stage

Percent of patients

Five
-
year survival, percent

I

7

90

II

41

84

III

25

75

IVA
-
B

28

58

Data from: Lee, AW, Sze, WM, Au, JS, et al. Treatment results for nasopharyngeal carcinoma in the modern era: The Hong
Kong experience. Int J Radiat Oncol Biol Phys 2005; 61:1107.


Q&A


Q: Why perform MRI if CT is correct?


A: Detect soft tissue lesion for tumor stage


Q: When we can

t different diagnosis?


A: performed special stain as soon as possible


Q: How can we do next time?


A: Read CT well



Inform pathology about special stain



Less invasive

CT versus MRI

Object


Less invasion


Less trauma


Less resource waste



Patient
-
centered management

Think about This


Surgeons: Do Everything, Know Nothing.


Internal Medicine: Know Everything, Do
Nothing.


Pathologists: Know Everything, Do Everything,
But Too Late.


Psychiatrists: Know Nothing, Do Nothing.



Team work and integration

Discussion in Division of Pediatric
Surgery (20081017)

Discussion in Division of Pediatric
Surgery (20081024)

Discussion in Division of Pediatric
Surgery (20081031)

Thanks for Your
Attention


AJCC(American Joint Committee on
Cancer) TNM staging system


T1 tumor confined to the nasopharynx


T2 tumor extending to soft tissues of oropharynx
and/or nasal fossa


T2a without parapharyngeal extension


T2b with parapharyngeal extension


T3 tumor invading bony structures and/or paranasal
sinuses


T4 tumor with intracranial extension and/or
involvement of cranial nerves, infratemporal fossa,
hypopharynx, or orbit.


AJCC(American Joint Committee on
Cancer) TNM staging system


N0 no regional lymph node metastasis


N1 unilateral metastasis in lymph node(s), 6cm or less
in great dimension, above the supraclavicular fossa


N2 bilateral metastasis in lymph node(s), 6cm or less in
great dimension, above the supraclavicular fossa


N3 metastasis in lymph node(s)


N3a greater than 6cm in dimension


N3b extension to the supraclavicular fossa


AJCC(American Joint Committee on
Cancer) TNM staging system


M0 no distant metastasis


M1 distant metastasis



Stage I T1 N0 M0


Stage IIa T2a N0 M0


Stage IIb T1 N1 M0


T2a N1 M0


T2b N0, N1 M0


Stage III T1 N2 M0


T2a, T2b N2 M0


T3 N0, N1, N2 M0


Stage IVa T4 N0, N1, N2 M0


Stage IVb any T N3 M0


Stage IVc any T any N M1