P21. PROLIFERATING TRICHILEMMAL TUMOUR: A CASE REPORT
Jeyaverasingam J, Toh YF, Chow TK.
University of Malaya.
Proliferating trichilemmal tumour is an adnexal neoplasm with outer root sheath differentiation. It commonly occurs in the scalp and base of neck in women. Malignant transformation is rare.
A 45-year old lady presented with an occipital mass for 5 years with occasional bloody discharge. The mass was 2 cm in size, painless and mobile. It was not fixed to the underlying skull. Clinically, it was suspected to be a lipoma. The mass was excised. The laboratory received two pieces of greyish white solid cystic, rubbery to firm nodule, focally covered by fibrous tissue. Microscopic examination showed mainly lobular proliferation and prominent infolding of neoplastic epithelial cells. The epithelial cells show peripherally palisaded small basaloid cells differentiating centrally into large keratinocytes with abrupt keratinization lacking a granular cell layer. Mitotic figures were rare. Focal invasion of malignant squamous epithelial cells into neighbouring tissues with margin involvement was observed.
Malignant transformation of proliferating trichilemmal tumour is rare. Its diagnosis is dependent on poor circumscription and invasion into the surrounding tissue. If there is no evidence of regional or distal metastases, the treatment of choice would be wide local excision with clear margins.
P22. MIXED DESMOPLASTIC AND CONVENTIONAL TYPE MELANOMA OF BREAST; A UNIQUE CASE WITH DIAGNOSTIC DILEMMAS
Farhana Mohammad Mohaidin, Nurul Akmar Misron
Department of Pathology, Hospital Sultanah Bahiyah.
Desmoplastic malignant melanoma is a rare variant of spindle cell melanoma, commonly seen in older adults, on sun-exposed areas.
We report a case of a 64-year-old malay lady presented with bleeding polypoidal breast lesion. No prior radiological examination done. She was subjected to excision of the lesion. Histologically the lesion is composed of two populations of tumour cells with different morphology and arrangement which lead to diagnostic dilemma to the pathologist. These tumour cells show variable positivity to vimentin, S100 and HMB-45 immunohistochemistry stains to reach to the diagnosis of malignant melanoma.
Desmoplastic melanoma itself is a rare variant of cutaneous melanoma, added to the location at the breast which further needs proper study for correct diagnosis and management.
P23. NEUROVASCULAR HAMARTOMA: A RARE PRESENTATION AS COLONIC POLYP
Farhana Mohammad Mohaidin, Nik Raihan Nik Mustapha.
Department of Pathology, Hospital Sultanah Bahiyah.
Neurovascular hamartoma is a rare entity, a benign and non-neoplastic lesion that consists of aberrant arrangement of non-epithelial tissue normally occurring in the intestine. It mostly involves the submucosa of small bowel and rarely affects the colon.
We report a case of neurovascular hamartoma occurring in large intestine of a 70 years old lady. She was referred from a health clinic to our centre for positive faecal occult blood test. Colonoscopy revealed a small (6 mm) polyp at sigmoid colon, which was then removed. Microscopically, this polypoid lesion was non-encapsulated and formed by a haphazard admixture of multiple large nerve bundles and thick-walled blood vessels within the submucosa. The overlying mucosa was non-dysplastic.
The low number of reported cases may reflect a genuine rarity of the lesion, or it may be due to it being unrecognized and thus, under-reported. It is debatable whether this lesion is truly a distinct hamartomatous lesion, or a result of nonspecific reactive phenomenon. Surgical resection is curative, and there have been no documented recurrences, owing to the non-neoplastic nature of the lesion.
P24. SOLID PSEUDOPAPILLARY TUMOUR OF PANCREAS
Barani Karikalan¹, Madhavan Manoharan², Siva Das Thuraisingham², Yeap Yean Lian³
¹Perdana University, Selangor, Malaysia
²Gribbles Pathology, Kuala Lumpur, Malaysia
³Hospital Fatimah, Ipoh, Malaysia
Solid papillary tumour of Pancreas (SPT) constitutes about 1-2% of all pancreatic neoplasms. It is a tumour of limited malignant potential occurring usually in young women. Microcystic adenoma, non-functioning islet cell tumor, mucinous cystic neoplasm, pancreatoblastoma, and calcified hemorrhagic pseudocyst are some of the differential diagnoses of this lesion. High rate of resectability of this tumor with good prognosis warrants high suspicion and accurate diagnosis of this lesion.
37-year-old patient presented with vague abdominal pain. Radiological examination revealed a retroperitoneal mass. Resection of the retroperitoneal mass was done. Specimen consisted of a circumscribed multilobated brownish mass weighing 468 grams and measuring 15x12x10cm. Cut surface showed a variegated appearance including multiple cysts measuring 1 to 3cm in diameter. Microscopically showed a cellular encapsulated tumour composed of solid, pseudopapillae and cystic areas. The pseudopapillae were covered by several layers of epithelial cells. The nuclei were ovoid with indistinct nucleoli and few mitoses. Hyaline globules and collections of foamy cells were seen. The thick fibrovascular cores showed prominent mucinous changes. Tumour clear cells were prominent. Extensive areas of haemorrhage and blood clots were seen. The blood vessels and lymphatics were unremarkable. Normal pancreatic tissue was seen at the edges of the tumour.
The most common location of the tumor is the tail of the pancreas, followed by the head, the body and the neck, lastly. SPTs have a wide range of appearance ranging from solid to cystic. But, a well encapsulated mass, with solid and cystic component has been considered to be typical imaging finding of SPPT. There is no identified radiological difference in benign and malignant component. We present a rare and interesting case of solid pseudopapillary tumour of pancreas presenting as a retroperitoneal mass lesion. A high suspicion of this tumour in young female patients, not only presenting with pancreatic mass but also retroperitoneal mass is required for correct diagnosis and management of the lesion.
P25. RARE PRESENTATION OF MYELOID SARCOMA IN A PATIENT WITH MYELOFIBROSIS.
Nor Hafizah Mohd Zain, Norakmar Tak
Department of Pathology, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan
Myeloid sarcoma (MS), also known as chloroma or granulocytic sarcoma, is a rare variant (<1%) of myeloid malignancy. It can present in isolation or frequently reported in 2-8% of patients with acute myeloid leukaemia (AML). It can precede AML in 25% of cases, coincide with AML in 15-35% of cases, or can occur after diagnosis of AML in 50% of cases. Less often, MS also may occur in association with myeloproliferative neoplasm (MPN) or myelodysplastic disorder (MDS). This is a first case of myeloid sarcoma reported in our hospital.
This is a case of a 48-year-old female who was initially diagnosed with myelofibrosis. Two months later, she presented with generalised lymphadenopathy, acute epigastric pain and fever. She underwent excision biopsy of the left inguinal lymph node. Later the bone marrow, trephine and immunophenotyping confirmed acute myeloid leukaemia. Histological findings showed total effacement of the lymph node by blast cells exhibiting uniform, round to oval nuclei with finely dispersed chromatin, inconspicuous nucleoli and scanty cytoplasm. The neoplastic cells are immunoreactive to myeloperoxidase, CD117, CD45 and focal CD68 and negative for TdT, CD3, CD5, CD20, CD79a, panCK, CD34 and CD10. She received a conventional AML-based induction regime with daunarubicin and cytarabine. However, on day eleven post-chemotherapy she developed an intracranial bleed and subsequently succumbed to the disease.
Myeloid sarcoma is an uncommon disease and there is no large prospective series reporting the prognosis of this condition. In this case report, the poor prognosis is related to previous diagnosis of myelofibrosis and the involvement of lymph nodes.
P26. LONG-STANDING CD4+/CD8+ WORINGER-KOLOPP DISEASE: A REPORT OF A RARE CASE
Sin Siuew Lim¹, Zuliatul Faizah¹, A Mohd Affandi²
¹Pathology Department, Hospital Kuala Lumpur, ²Dermatology Department, Hospital Kuala Lumpur
Woringer-Kolopp disease is a localized pagetoid reticulosis (PR). It is a very rare variant of mycosis fungoides (MF).
A 44-year-old Malay lady presented with intermittent pruritic erythematous papular lesions over the right for about 20 years but did not seek treatment. The lesion gradually increased in size and turned into a verrucoid plaque. Ultimately, it became ulcerated and is associated with foul-smelling pus discharge. On examination, a large, verrucous plaque (16cm) with ulceration and erosion on the right heel, extending to the lower is calf is seen. No other cutaneous lesions are present. Systemic and lymph nodes examination are negative. Skin biopsy cultures and Tuberculous Polymerase Chain Reaction (TB PCR) are negative. HPE reveals neoplastic T-cells with cerebriform nuclei, perinuclear halo and nuclear pleomorphism confined to the epidermis. These cells are positive for LCA, CD3, CD4, CD5 and CD8. Other relevant immunostains were negative. The proliferative index is high (>80%). Magnetic resonance imaging (MRI) of the right leg shows suspicious regional tendon involvement. Staging computerized tomography (CT) scan shows no disseminated disease. No atypical lymphocytes seen in peripheral blood smear. Infective screenings are negative.
PR is an indolent disease with excellent prognosis as opposed to primary cutaneous aggressive epidermotropic CD8+ T cell lymphoma (PCACTL), its disseminated form. Histopathologically, PR has to be distinguished from conditions which are associated with pagetoid epidermotropic growth and other acral presentations of T-cell lymphomas such as MF palmaris et plantaris (MFPEP), PCACTL and Type-D lymphomatoid papulosis (LP-D). Co-expression of CD4 and CD8 in PR is rare but has been described in several literatures. Till date, localized radiation therapy produces the best treatment response.
P27. THE UTILITY OF MUC4 IMMUNOSTAIN TO DECODE THE DIAGNOSIS OF A LOW GRADE FIBROMYXOID SARCOMA WHICH PRESENTS AS AN INCIDENTAL PULMONARY MASS: A CASE REPORT
Sin Siuew Lim¹, Hemlata Kumari¹, Noraini Mohd Dusa¹, Narasimman Sathiamurthy²
¹Histopathology Unit of Pathology Department, Hospital Kuala Lumpur
²Thoracic Surgery Unit, Surgery Department of Hospital Kuala Lumpur
Low grade fibromyxoid sarcoma (LGFMS) is a rare soft tissue tumor that has the predilection to grow in deep soft tissue areas of proximal extremities and trunk. It is rarely described within the thoracic cavity. When LGFMS is found in the lung and pleura, this should prompt the investigation for the possibility of a metastasis.
A previously well and asymptomatic 19-year-old Malay gentleman was incidentally found to have a right lower lobe lung mass in his chest X-ray when medical check was conducted prior to university enrolment The computed tomography (CT) thorax performed showed presence of a right lower lobe peripheral lung mass measuring 4.6 x 3.0 x 3.9cm. CT guided lung biopsy showed no granuloma or malignancy. The mass was excised and macroscopic examination revealed a well-circumscribed mass with fibromyxoid cut surface measuring 60x40x25mm attached to adjacent lung tissue measuring 40x17x17mm. Microscopy shows moderately cellular tumour mass with focal areas of invasion into the adjacent lung tissue. The mass is composed of bland spindle-shaped cells arranged in a storiform to swirling pattern set in a collagenous stroma with alternating myxoid areas. There is no mitosis or necrosis. No evidence of dedifferentiation seen. In areas, also noted entrapped alveolar pneumocytes within the mass. The spindle cells show diffused immunoreactive for MUC4 and focal immunoreactivity for TLE1 with all other immunostains being negative.
LGFMS is a rare, slow-growing fibroblastic neoplasm with common lung metastases. The diagnosis of LGFMS is also very challenging as it can be mistaken for many benign spindle cell lesions with myxoid stroma. An accurate diagnosis of LGFMS is important due to its significant potential of recurrence and late metastatic spread. Due to the high risk of late metastasis, a prolonged clinical follow-up is required.
P28. A CORRELATION OF E-CADHERIN EXPRESSION WITH THE OUTCOMES OF PROSTATE CANCER AMONG MALAYSIAN POPULATION.
Siti Farah Sophia Mohd Nasir¹´², Ikmal Hisyam Bakrin1, Norhafizah Mohtarrudin¹, Rosna Yunus².
¹Pathology Department, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor
²Pathology Department, Hospital Kuala Lumpur, Kuala Lumpur.
Aberrant expression of E-cadherin has correlation with an advanced disease in prostate cancer patients in Hospital Kuala Lumpur. In this study, the researchers have evaluated the potential of E-cadherin as a prognostic marker in prostate cancer and its correlation with the outcomes of prostate cancer patient.
Materials and methods:
Paraffin block tissue from 46 prostate cancer patients that underwent prostatectomy which meet the inclusions and exclusions criteria were retrieved from 2008 to 2016. Immunohistochemistry study of E-cadherin was performed. E-cadherin expression was evaluated as weak (score 1+), moderate (score 2+) and strong (score 3+). Statistical analysis was used to determine the correlation of E-cadherin with the outcome of prostate cancer patients which includes biochemical failure, disease free, metastasis and local recurrence. The correlation of E-cadherin expression with currently use traditional clinicopathological parameters (pathological staging, Gleason score, positive tumour margin and perineural invasion) were also subsequently evaluated.
Results and Discussion:
E-cadherin immunostaining results showed membranous E-cadherin expression in prostate cancer cells. There was significant correlation between E-cadherin expression and biochemical failure (p=0.005) as well as local recurrence (p=0.003). However, there was no significant correlation between E-cadherin expression with disease free (p=0.864) and tumour metastasis (p=0.430). When we compared the correlation of E-cadherin expression with the traditional clinicopathological parameters, there was significant correlation observed between E-cadherin expression with pathological staging (p=0.001), Gleason score (p=0.004) and perineural invasion (p=0.001). There was no significant correlation between E-cadherin expression with positive tumour margin (p=0.320).
The results suggest the usefulness of E-cadherin as a prognostic tool in prostate cancer and can be used as an additional marker for the current available traditional clinicopathological parameters. It also has a good value in predicting the outcome of prostate cancer patients, particularly the biochemical failure and local tumour recurrence. A molecular study can be implemented to understand the genetic event involve in the inactivation of E-cadherin in prostate cancer.
P29. A REVIEW OF HEPATECTOMIES IN HOSPITAL SULTANAH BAHIYAH
Ranjeeta Krishnan, Pavitratha Puspanathan
Pathology Department, Hospital Sultanah Bahiyah, Alor Setar
Hepatic resections are performed for both benign and malignant neoplasias. Malignancies contribute to a large number of hepatectomies done at Hospital Sultanah Bahiyah as it is a tertiary Hepatopancreaticobiliary surgery centre. This study looks at hepatic resection specimens, relating epidemiology and contributing factors.
This is a retrospective hospital based study looking at hepatic resections performed from July 2017 to December 2017. Forty-four patients underwent hepatic resection for space occupying lesions and traumatic injuries. Various epidemiological factors, predisposing conditions and histopathological findings were studied.
From the 44 patients, there were 24 males and 20 females with the age range of 3-81 years. Fourty two resections were for neoplastic lesions and two for trauma related. Out of fourty two resections, fourteen for benign conditions such as cavernous haemangiomas, focal nodular hyperplasia, liver cysts and hepatic adenoma. Twenty-eight were for malignant lesions, namely hepatocellular carcinoma (HCC) and metastatic malignancies predominated, followed by cholangiocarcinoma, hepatoblastoma and embryonal sarcoma. Out of the twelve HCC cases, only two were positive for Hepatitis B/C and three had established cirrhosis. Colorectal primary was the more prevalent (50%) for secondary malignant liver lesions.
Over the period of 6 months, malignant neoplasms represented the major reason for liver resection. Non-neoplastic lesions like simple liver cysts, focal nodular hyperplasia and established cirrhosis showed female predominance while benign neoplasms like cavernous haemangioma also show similar predominance. Of the malignant liver tumours, hepatocellular carcinoma and metastatic malignancies were the commonest, with a predominance of colorectal metastases in our setting.
P30. A STUDY OF HER2 EXPRESSION IN ENDOMETRIAL CARCINOMA: A SINGLE CENTRE EXPERIENCE
Mariani Hashim¹, Nur Maya Sabrina Tizen¹, Nurwardah Alfian¹, Hasmah Hashim², Azmawati Mohammed Nawi³, Suria Hayati Md Pauzi¹
¹Departments of Pathology, Hospital Canselor Tuanku Mukhriz, Universiti Kebangsaan Malaysia, ²Departments of Pathology, Hospital Melaka, ³Department of Community Health, Hospital Canselor Tuanku Mukhriz, Universiti Kebangsaan Malaysia.
Endometrial carcinoma (EC) is the seventh most common cancer in females in Malaysia, the majority of which are composed of lower grade type I EC. Although lesser prevalent, type II EC which is of higher grade has poorer outcome and prognosis. Human epidermal growth factor receptor 2 (HER2) is one of possible prognostic molecular marker which can be a target for immunotherapy. This study aimed to assess the expression of HER2 in common type of EC in local population and to determine its correlation with the clinicopathological features.
Materials and Methods:
A total of 53 cases of endometrioid type of EC were selected within six-year period comprising of 22 cases of grade 1, 25 cases of grade 2 and 6 cases of grade 3 carcinoma. The selected whole tumour tissue sections were immunostained with HER2 antibody. The scoring was semi-quantitatively analyzed based on 2013 American Society of Clinical Oncology (ASCO)/College of American Pathologists (CAPs) guidelines for scoring of HER2 in breast cancer.
Results and Discussion:
All cases regardless of grades of endometrioid carcinoma show negative expression of HER2 (score 0). All control tissues are working.
There is no significant HER2 expression in endometrioid carcinoma. However, a follow-up study with larger number of samples from different type of endometrial carcinoma is useful. Testing several tumour tissue blocks to assess possible tumour heterogeneity as well as correlation with HER2 gene amplification status by in-situ-hybridisation are also recommended.