[醫如往常] Senior Clerkship Day 110: Pathology: IHC Markers

IHC Markers

鄭醫師

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Pleomorphic undifferentiated sarcoma(abbreviated PUS), also undifferentiated pleomorphic sarcoma and previously malignant fibrous histiocytoma(abbreviated MFH), is a type of soft tissue sarcoma.

PUS occurs most commonly in the extremities and retroperitoneum, but has been reported in other sites. Metastasisoccurs most frequently in the lungs (90%), bones (8%), and liver(1%).

來自 <https://www.wikiwand.com/en/Pleomorphic_undifferentiated_sarcoma>

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IHC

Peroxidase

Purple DAB+H2O2->O2+H2O+brown DAB

AEC紅色

Fab+Fc<2nd Ab< enzyme

avidin biotin complex 許世明副院長

Endogenous biotin background interference

Fab+Fc<2nd Ab-PPP 只要三小時

一次抽血

Mouse 200 ul

Rabbit 50 ml

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Counterstain

Blue hematoxylin

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Melanoma

S-100 (paraganglion也有)

HMG45

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Glioma(Astro, Ependymomas, GBM)

GFAP; glial fibrillary actin protein

Oligodendroma

FISH: 1p19q 自費一萬元

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Hematology

T CD3

B CD20

NK CD56

Macrophage CD68

Myeloid MPO

Hodgkin CD30

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Sarcoma

Rhabdomyosarcoma, embryonal: mRNA myogenin

Leiomyosarcoma: desmin

Angiosarcoma CD31

Liposarcoma lipoblast

Amplification of MDM2, CDK4

GIST

C-kit

Dog-1

Synovial sarcoma

CK, TLE-1

MPNST

s-100(-), fibroblast H3K27Me3

不用染IHC的:

Osteosarcoma osteoid

Chondrosarcoma cartilage

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Carcinoma

Squamous cell carcinoma

P40

(p63, squamous, basal 都有)

Cervix HPV 抑制p105RB, 表現p16

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Adenocarcinoma

Prostate: PSA

Lung: TTF-1 (Routine 已經變成用分子定義了)

ALK1

Breast: ER, PR, Her2, GATA3

Liver: HepPar 1 (直接到liver cells到老鼠做出來的antibody, antigen不明) sensitivity 80%

Arginase 1: sensitivity 90%

Stomach, Colon: CDX-2 (mRNA)

Gyn/GU: Pax-8 (mRNA)

Pancreas, gall bladder: morphology

Stomach: annexin A10 for signet ring cells

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Molecule

EGFR

KRAS

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IHC

Herpes

CMV

NTUH沒有進:

Adenovirus

Helicobacter pylori

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Collision tumor

gastrointestinal epithelial malignant tumor (EMT)

epithelialmesenchymal transition (EMT)

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[醫如往常] Senior Clerkship Day 109: Pathology: Prostate cancer

Prostate cancer 王醫師
Prostate
• 1536 Massa
• 1538 Vesalius first illustration, father of anatomy
• 1853 prostate cancer
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Cancer
• Solid internal organ
• Not always mass forming
• Asymptomatic,. Transitional zone
• Not self examination


台灣發生率第五名
台灣死亡率第七名


Non specific
Back pain


PSA
NHI 400P
US $22
• Minimal invasive
• Sensitive
• Affordable cost
• Widely available
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Risk stratification by NCCN
Stage
Serum PSA
PSA density
PSA velocity
Gleason score 3+3,. 5+5
Number of cores
Laterality


Biopsy
四個區塊  前中後 共12次


Very low
<2/12
Unilateral 國際沒有管
<50% area
PSA<0.15
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Tumor staging


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Radical prostatectomy
Complications
• Erection problem
• Incontinence
• Nerve damage
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Active surveillance
• Regular follow up
• 3-6 months
• DRE
• PSA
• Treatment when tumor progression
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TRUS P biopsy
Adipose involvement
Seminal vesicle invasion
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Prostate Concretion amyloid
正常不規則
癌化反而變平滑


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Triple immunostain
Brown: basal cell
P63
HMWCK
Magenta: cancer, benign
AMACR


NKX3.1 Cancer表現下降
細胞核 marker
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Specimen identification
宋醫師被切除
告曹醫師
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False negative


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Gleason score
In the present form of the Gleason system, prostate cancer of Gleason patterns 1 and 2 are rarely seen. Gleason pattern 3 is by far the most common.
• Pattern 1 - The cancerous prostate closely resembles normal prostate tissue. The glands are small, well-formed, and closely packed. This corresponds to a well differentiated carcinoma.
• Pattern 2 - The tissue still has well-formed glands, but they are larger and have more tissue between them, implying that the stroma has increased. This also corresponds to a moderately differentiated carcinoma.
• • Pattern 3 – • Recognizable glands, but the cells are darker. Beginning to invade the surrounding tissue or having an infiltrative pattern.
• Pattern 4 – • Few recognizable glands. Many cells are invading the surrounding tissue in neoplastic clumps.
• Pattern 5 – • No / few recognizable glands. Sheets of cells throughout the surrounding tissue.




來自 <https://en.wikipedia.org/wiki/Gleason_grading_system>


Gleason scores range from 2 to 10
Gleason score ≤ 6 (prognostic grade group I);
Gleason score 3+4=7 (prognostic grade group II) indicating the majority is pattern 3;
Gleason score 4+3=7 (prognostic grade group III) where pattern 4 is dominant;[4]
Gleason score 4+4=8 (prognostic grade group IV);
Gleason scores 9-10 (prognostic grade group V).[5]
Prostate cancers with a Gleason score ≤ 6 usually have rather good prognoses.
來自 <https://en.wikipedia.org/wiki/Gleason_grading_system>


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John Hopkins Dr. Epstein
看一次$250
一年看一萬片


全部病理九萬件


Home of world famous chicken
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Ddx
Small tumor focus
Innocent looking tumor
• Atrophic variant
• Pseudohyperplastic variant
• Foamy gland variant
Benign mimickers
• Adenosis
• Verumontanum gland hyperplasia
• Nephrogenic adenoma
Extraprostatic origin
• UC; urothelial carcinoma
• Bladder adenocarcinoma
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[醫如往常] Senior Clerkship Day 108: Pathology: Kidney

林醫師

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Sinus fat

Papilla pelvis

Pyramid

Gerota's fascia

T12-L3

Perirenal, pararenal fat

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Endothelial fenestrae 70-100nm

Mesangial

GBM

Lamina rara interna

Lamina densa

Lamina rara externa

Podocytes foot process 20-30nm visceral epithelium

Parietal epithelium

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Macula densa of distal tubule chemoreceptor

JGA baroreceptor

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90% renal cortex composes tubules

Proximal tubule, brush border 比較紅

Shock segments

Toxin continuous

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Interstitium

Ccr, BUN

Per min

1000cc renal artery

900cc renal vein

GFR 100

Urine 1

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Renal artery

Seg

Interlobar

Arcuate

Intralobar

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Percutaneous biopsy

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HE

Silver

Masson Trichrome

PAS

3um

Immunofluorescence

IgG, IgM, IgA, C3, C1q, kappa, lambda

Tubules deposition nonspecific

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Subepi.  Membrane

Mesengial IgA

Subendo lupus, MPGN

DIf

Cryo

Acetone

PBS

FITC

PBS

PermaFluor

Dark

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Goodpasture disease

Goodpasture syndrome (GPS; also known as Goodpasture’s disease, antiglomerular basement antibody disease, or anti-GBM disease) is a rare autoimmune disease in which antibodies attack the basement membrane in lungs and kidneys, leading to bleeding from the lungs and kidney failure. It is thought to attack the alpha-3 subunit of type IV collagen, which has therefore been referred to as Goodpasture's antigen.[1] Goodpasture syndrome may quickly result in permanent lung and kidney damage, often leading to death. It is treated with immunosuppressant drugs such as corticosteroids and cyclophosphamide, and with plasmapheresis, in which the antibodies are removed from the blood.

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EM

Glutaraldehyde

1um, 50-70nm for EM

Thin basement disease

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RPGN Ccr兩倍 in  3 month. Crescent

Type 1

Goodpasture

Linear deposition of IgG in GBM

NC1 domain

Type 2

Immune complex

SLE, IgA, type MPGN

Type 3

Pauci immune

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MPGN

Type 2 DDD, dense deposit disease

 Lamina densa, Bowman's capsule, renal tubules

Recurrence after transportation

C3 glomerular deposition atypical HUS

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Thin basement disease

400 →200 nm

Type 4 collagen

Alpha 3,4 subunit defect

Deafness

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Alport syndrome

X linked

Alpha 5 subunit

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15% AR type

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DM nephropathy

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Myeloma

Kappa 多

Light chain

Bence Jones protein

Cast nephropathy

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Amyloid

Beta birefringence

AA, AL type most common

Inflammation AA 未開發

Light chain AL 已開發 lambda

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ATIN, AIN

Chinese herb nephropathy

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Granular kidney

Hypertension

Compensatory hypertrophy

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Rejection

器官經濟學

Endothelial double contour

C4d

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RCC 70%

Clear cell 70%

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UC

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[醫如往常] Senior Clerkship Day 107: Pathology: Mixed Germ cell tumor

SPC 梁醫師
Mixed Germ cell tumor 40M left retroperitoneal tumor with flank pain
AFP4000 ng/ml
Dopamine 550 ug/24h
Rule out
1. Castleman disease
2. Psoas fibrous tumor
3. Leiomyosarcomasarcoma
4. Liposarcoma


Calcification
Vessel invasion
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Mature teratoma GFAP
Immature
Microcystic
Schiller-Dual Body (glomerular like)
CD30 embryonal carcinoma
Yolk sac tumor cd117
Choriocarcinoma HSD3D1
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年紀越大， yolk sac tumor ratio越大
Adult may combine hematopoietic neoplasms
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Pediatric type
Age>12 is adverse
I(12p) is rare
Sacrococcygeal>>mediastinum
If it combines YST or other type, not a bad sign
Conservative approach
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Children prepubertal type
6 year survival rate >80% with platinum
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Extragonal adult type
比照non seminoma處理
常常是occult testes
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EC 是不好的
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Puberty 也可能長prepubertal type
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Germ cell neoplasm in situ 是post pubertal 特徵
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1cm3, 送cytogenetics
20000自費
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[醫如往常] Senior Clerkship Day 107-108: Pathology: Breast

Morning Meeting
LAM; Lymphangioleiomyomatosis
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Paraganglioma
GATA 3 +
S100 +
Ck -
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Breast
Diabetes mastopathy
Lymphocyte infiltration
Big fibroblast
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Parotids sebaceous lymphadenoma
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Skin hyperpigmentation
Fine chromatin
Tdt trace
CD3 -, 79a -
CD123, 56, 4 +
Blast
Plasmacytoid dendritic cell neoplasm
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Haematoma
Cartilage 旁邊有東西
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連醫師
Breast cancer
MRM
Simple
Partial/ BCT, lumpectomy
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Facial margin
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Serial slicing
Med. to lat.
3-5mm
May skip
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RCC Stage 1<7cm
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Breast Mass 10cm, may be DCIS
Clinical, pathology discrepancy


外面醫院考慮成本 只能切五片
NTUH切四十片
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Random for multifocal
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ALND
至少要10顆
小於十顆會被核刪
Multislice 2mm
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美國病理最便宜的180美金
台灣從一千到五千點
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2003開始sentinel lymph node. 通常2,3顆， 最多做過10顆
Blue cassette
500 um


可能false negative tumor塞滿


IHC 染ck


Isolated tumor cell clusters <200 cells, <0.2mm
pN0 i+
ITCs
可是NEJM2009 還是有差異
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Van Nuys Prognostic classification
RT for DCIS
Age
Grade
Margin
Size
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ER, PR
Her2
Ki67 proliferation
14% low
20% high
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FISH 可以與二十年前蠟塊
PCR
Microarray fresh tissue RNA
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UCLA Jews Her2 tyrosine kinase
Amplification, overexpression
Chromosome 17
Her2/centromere>2.0
Counts 20 cells
一萬元


IHC 2+ 做FISH
3+ 直接用Herceptin 80萬
(Protein unstable)


Doxorubicin(Adriamycin)
Herceptin Trastuzumab
都有cardiotoxicity


Heart development Her2
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Imatinib (Glivec) CML


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Colon
EGFR 60%
Ras 40%
Raf


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Lung
EGFR exon 18,19,20,21
19 5 deletion
21 1 deletion l858r


T790m
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Quality control sensitivity
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Ewing sarcoma
T 22, 11
PCR
FISH
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Day 108
Morning Meeting
Breast cancer with SPC; Solitary papillary carcinoma


Increased, in situ, borderline, invasive
• CAIX
• MCT4
Decreased


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Invasive tumor with SPC >
Pure in situ Spc with conventional DCIS


• Mucinous type
• WT1, Muc2


CA9 loss of basement membrane (type iv collagen)
• Old
• Spindled tumor
• ER, PR,chromogranino


• Smaller size <20mm
• Lower grade grade 1
• Older age
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Type B neuroendocrine
• Synaptophysin
• Chromogranin A
• CD56
• NSE
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No significant difference between
Invasive carcinoma with SPC and without SPC
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Prostate幾乎都有neuroendocrine change
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[醫如往常] Senior Clerkship Day 106: Pathology: markers

孫法醫師

Frozen

O.C.T:optimal cutting temperature compound -19--21度

Molecule Liquid Nitrogen -85度

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Special stain

Congo red: Amyloid

Copper: Wilsons' disease

PAS; Periodic acic Schiff stain: glycogen, MPS, capsule, fungus

DPAS; diastase : salivary

Silver: hepatoma
Orcein: elastic fiber, aneurysm, AVM

Von Kossa 照光: Calcium

Warthin-Starry: spirochette

PTAH(Phosphotungstic 鎢 acid haematoxylin): striation (rhabdomyosarcoma), fibrin (DIC)

Fresh tissue:

Fat stain

Thio-acetylcholine esterase (AchE): megacolon, lamina propria

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IHC

CD30: Anaplastic large cell lymphoma (ALCL)

classical Hodgkin Lymphoma Reed-Sternberg cells

CD45: CLA; common leukocyte antigen

CD68: macrophage

CD117(c-kit): GIST

plasmacytoma lambda常見

CK7: UGI

CK20: LGI

Ki-67: proliferation

P63: breast myoepithelial cells

GFAP: glioma

ALK: Lung

P40: SCC

MSH6: MSI; microsatellite instability

TTF-1: Thyroid, lung adenocarcinoma

Synaptophysin, Chromogranin: Neuroendocrine peptides

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Positive, negative control

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白色 biopsy

黃 大件檢體

綠色 切兩片

藍色 牙科

粉紅色 autopsy

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10% neutral formalin (4% formaldehyde) 10x tissue量 + phosphatate buffer

滲透 1mm/ 1 hr

極限:五小時 上下加起來1cm

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Pancreas autolysis, fat necrosis

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Alcohol dehydration

Large cell -> small cell

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兩小時內

Bouin's solution-> bone marrow, spermatozoa

Masson's trichrome refixation

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Carnoy's solution -> EBV -> NPC

Acetic acid 冰

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吳法醫師

CD 79a pan B cells

CD 20 mature B cells

CD10 follicle cells

CD23 dendritic cells,  marginal type small BCL

BCL-2 apoptosis

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Myocarditis治療

Hypothermia

ECMO Bypass

[醫如往常] Senior Clerkship Day 105: Lab Medicine: 國家級臨床試驗研究中心

國家級臨床試驗研究中心

FFPE Formalin-fixed, paraffin-embedded

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一次八千元

EGFR

2573

2369

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Kras +egfr 16000

四天發報告

四年現在兩萬例

NGS 一次十萬

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蘇助理教授

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CR complete

PR partial

SD stable

PD; Progress disease

Response rate cr+pr

Control sd pr cr

Tki 一顆2000元

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IVD In vitro diagnosis

LDT lab developed test

------------

Mass diagnosis

DNA Sample

Amplification

Detection, probe在突變前一個nucleotide

Analysis

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Kras smoking

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Cancer panal 52

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Clinical interpretation based report of NGS

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Afatinib 楊志新成名

10-12 month

T790m  mutation 60%

Azd9291

12-23 weeks

C797s mutation

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Drug resistance

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Circulation tumor dna; ct DNA

Cell free dna ; cf Dna

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Liquid biopsy

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PD1 只對20%有用

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