SL-26 Pulmonary Pathology Slide Seminar Case 3 Lucian R. Chirieac, - - PowerPoint PPT Presentation

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SL-26 Pulmonary Pathology Slide Seminar Case 3 Lucian R. Chirieac, - - PowerPoint PPT Presentation

Apr 17, 2023 253 likes •634 views

SL-26 Pulmonary Pathology Slide Seminar Case 3 Lucian R. Chirieac, M.D. Department of Pathology Brigham and Womens Hospital Harvard Medical School Boston, MA HARVARD BRIGHAM AND MEDICAL SCHOOL WOMENS HOSPITAL Case 3 42-year-old

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SL-26 Pulmonary Pathology Slide Seminar Case 3 Lucian R. Chirieac, M.D.

Department of Pathology Brigham and Women’s Hospital Harvard Medical School Boston, MA

BRIGHAM AND WOMEN’S HOSPITAL HARVARD MEDICAL SCHOOL

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Case 3

42-year-old male who presented with flu-like symptoms and shortness of breath. Imaging reveals pericardial

  • effusion. Evacuation and pericardial cytology was benign

(abundant neutrophils and occasional reactive mesothelial cells). Pleural fluid, cytopathology report was negative for malignant cells.

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Case 3

Cardiac MRI - circumferential 8 mm thickening of pericardium, with reduced left ventricular ejection fraction. Surgery - anterior pericardium, pericardiectomy. A full dissection of the pericardium from the left ventricle was attempted but not feasible. Chest and abdomen CT scan

  • Pericardial thickening and pericardial effusion, right pleural effusion with

subcentimeter noncalcified nodules.

  • Passive hepatic congestion, likely reflecting constrictive pericarditis.
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Case 3

Medical History

  • Hodgkin's disease, nodular sclerosing
  • Diagnosed in 1987
  • Treated with external beam radiation and splenectomy
  • Hepatitis
  • Hypothyroidism
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H&E 400x

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H&E 400x

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H&E 200x

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H&E 400x

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H&E 400x

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H&E 1000x

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Differential Diagnosis

  • Metastatic Carcinoma: should be further investigated by

immunohistochemistry, CT exam and/or biopsies if clinically indicated.

  • Angiosarcoma: epithelioid histology
  • Malignant Solitary Fibrous Tumor
  • Malignant Mesothelioma
  • Germ Cell Tumor
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AE1/AE3 200x

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Calretinin 200x

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Calretinin 600x

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WT-1 100x

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D2-40 200x

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Immunoperoxidase Studies

ANTIBODY RESULT COMMENT

Cytokeratin + Positive CK 7 + Positive D2‐40 + Membranous, positive Calretinin + Positive WT‐1 + Positive, nuclear CK 20 ‐ Absence of cytoplasmic staining TTF‐1 ‐ Absence of nuclear staining CEA ‐ Absence of staining S100 ‐ Absence of staining Melan–A ‐ Absence of staining HMB‐45 ‐ Absence of staining p63 ‐ Absence of staining CDX2 ‐ Absence of staining

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Unusual Subtype of Mesothelioma

Diffuse Malignant Mesothelioma, Epithelioid type

  • Pleomorphic subtype
  • Involving the pericardium
  • Secondary to therapeutic radiation
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Unusual Subtype of Mesothelioma

Diffuse Malignant Mesothelioma, Epithelioid type

  • Pleomorphic subtype
  • Involving the pericardium
  • Secondary to therapeutic radiation
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Unusual Subtype of Mesothelioma

Diffuse Malignant Mesothelioma, Epithelioid type

  • Pleomorphic subtype
  • Involving the pericardium
  • Secondary to therapeutic radiation
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Unusual Subtype of Mesothelioma

Diffuse Malignant Mesothelioma, Epithelioid type

  • Pleomorphic subtype
  • Involving the pericardium
  • Secondary to therapeutic radiation
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Unusual Subtype of Mesothelioma

Diffuse Malignant Mesothelioma, Epithelioid type

  • Pleomorphic subtype
  • Involving the pericardium
  • Secondary to therapeutic radiation
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Pathologic Classification of Diffuse Malignant Mesothelioma

Epithelioid mesothelioma Sarcomatoid mesothelioma (spindle cell) Desmoplastic mesothelioma (variant of sarcomatoid mesothelioma) Biphasic mesothelioma

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Epithelioid MM Sarcomatoid MM Biphasic MM Biphasic MM

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Overall Survival (%)

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Histologic Subtypes and Patterns of Malignant Mesothelioma

Epithelioid Mesothelioma

Tubulopapillary Micropapillary Trabecular Acinar Adenomatoid Solid Clear cell Deciduoid Adenoid cystic Signet ring cell Small cell Rhabdoid Pleomorphic

Sarcomatoid Mesothelioma

Conventional, spindle cell Desmoplastic Heterologous differentiation (osteosarcomatous, chondrosarcomatous, etc.) Lymphohistiocytoid (may also be classified as epithelioid)

Biphasic/Mixed

2018 U pdate o n the Guide line s by the I MiG Re c o mme ndatio ns

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Histologic Subtypes and Patterns of Malignant Mesothelioma

Epithelioid Mesothelioma

Tubulopapillary Micropapillary Trabecular Acinar Adenomatoid Solid Clear cell Deciduoid Adenoid cystic Signet ring cell Small cell Rhabdoid Pleomorphic

Sarcomatoid Mesothelioma

Conventional, spindle cell Desmoplastic Heterologous differentiation (osteosarcomatous, chondrosarcomatous, etc.) Lymphohistiocytoid (may also be classified as epithelioid)

Biphasic/Mixed

2018 U pdate o n the Guide line s by the I MiG Re c o mme ndatio ns

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Malignant Mesothelioma Pleomorphic Histology

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Adapted from MESOPATH reference center 1998 et 2010. Courtesy Dr. Francoise Gallateau‐Salle

Overall survival by histologic type in 2582 patients with diffuse malignant pleural mesothelioma

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Unusual Subtype of Mesothelioma

Diffuse Malignant Mesothelioma, Epithelioid type

  • Pleomorphic subtype
  • Involving the pericardium
  • Secondary to therapeutic radiation
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Malignant Mesotheliomas Arising in Patients with a History of Radiation

Chirieac et al. J Clin Oncol. 2013 Dec 20;31(36):4544‐9 Unpublished Data

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Cumulative frequency (Kaplan Meier estimate) of Malignant Mesothelioma in patients who received therapeutic radiation. The median latency interval is 19.25 years in 90 patients with pleural, peritoneal and pericardial mesotheliomas secondary to therapeutic radiation reported in the literature.

Malignant Mesotheliomas Arising in Patients with a History of Radiation

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Chirieac et al. J Clin Oncol. 2013 Dec 20;31(36):4544‐9

Malignant Mesotheliomas Arising in Patients with a History of Radiation

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Table 1. Clinical and Pathologic Characteristics of Patients with Lymphoma-associated PDMM and Asbestos-associated PDMM. Lymphoma- associated PDMM Asbestos- associated PDMM Characteristic (N=22) (N=1596) P Value* Sex – no. (%) 0.82 Female 5(22.7) 331 (20.7) Male 17 (77.93) 1265 (79.3) Age – (years) <0.0001 Mean 46.7 63.3 Median (range) 45 (27-79) 64 (17-93) Asbestos bodies* (count/g) 0.0007 Mean 21 5850 Median (range) 15 (0-56) 325 (0-1.4x106) Histology – no. (%) 0.21 Epithelioid 17 (77.3) 973 (60.9) Biphasic 5(22.7) 502 (31.5) Sarcomatoid 0(0) 121 (7.6) Primary location† – no. (%) 0.44 Left Pleura 12 (54.5) 646 (41.0) Right Pleura 10 (45.5) 927 (58.9) Surgery‡ – no. (%) 0.71 Complete macroscopic cytoreduction 13 (76.5) 884 (80.1) Incomplete resection 4(23.5) 219 (19.9)

Chirieac et al. J Clin Oncol. 2013 Dec 20;31(36):4544‐9

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36 72 108 144 180 20 40 60 80 100

Asbestos- associated PDMM Lymphoma- associated PDMM P=0.02

Time (months) Overall Survival (%)

Overall Survival of Patients with Malignant Mesotheliomas Arising in Patients with a History of Radiation

Chirieac et al. J Clin Oncol. 2013 Dec 20;31(36):4544‐9

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Summary

  • Diffuse malignant mesothelioma, epithelioid type, pleomorphic

subtype is a distinct entity of special interest which has a poor prognosis similar to sarcomatoid mesothelioma.

  • Patients with malignant mesothelioma secondary to therapeutic

radiation have unique features:

  • Unique, rare histologic subtypes, including pleomorphic.
  • Young age ( aprox 40 years)
  • Arise in patients with a history of therapeutic radiation 20 years later.
  • Pericardial mesotheliomas are exceedingly rare.
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Follow Up

  • 1 month - Started the first cycle of chemotherapy with

pemetrexed and cisplatin

  • His course has been complicated by acute renal failure.
  • 12 months - CT abdomen and pelvis
  • Intraperitoneal fluid
  • Multiple soft tissue mesenteric nodules suggestive of progression of

patient's known malignant mesothelioma.

  • Enlarging bilateral pleural effusions.