Title: Pilomatrixoma With Atypical Features: Case Report And Review Literature
Authors: Meina Missak MD1, Aaron Haig MD1, Manal Gabril MD1
1Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, Canada
Abstract: Pilomatrixoma is an uncommon, benign tumor with differentiation towards both the hair matrix and cells arising in the cortex most frequently appearing in the first or second decade of life (1). In rare instances, pilomatrixomas can show malignant transformation. Pilomatrix carcinoma is extremely uncommon and has traditionally been considered a tumor of low malignant potential, however a high local recurrence rate has been reported. There is a paucity of literature on these lesions, with only a few reports describing the spectrum of malignant changes seen in these lesions. In this report we present a case of pilomatrixoma in a 57-year-old male patient showing atypical features. While the tumor is small, there are features that suggest a progression to malignancy, but do not fulfill the criteria for pilomatrix carcinoma. The atypical features identified include a focal infiltrating border, focal necrosis and an increase in mitotic activity. Some of the features identified were similar to a subset of pilomatrixoma, known as ‘proliferating pilomatrixoma’. However, the lesion in this case, did not have the diffuse changes or larger size that has been frequently reported. (2) . In conclusion, given the lack focality of the changes, the lesion in our case is best described as a pilomatricoma with atypical features. As the malignant potential is unknown, wide excision was recommended. Furthermore, our case may highlight the need to ensure close clinical follow up for these lesions with unexpected atypical features for the concern of recurrence and malignant transformation.
Position: Pathologists’ Assistant
Title: Diy Virtual Pathology Gross Rounds: A Covid-19 Teaching Initiative Pilot
Authors: Amy Calovini BSc MClSc 1, Brian Chow MSc PA(CCCPA) MLT 1, Carlo Hojilla MD PhD FRCPC 1,2
1Department of Pathology and Laboratory Medicine, Sinai Health System, Toronto, Ontario, Canada 2Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
Abstract: Introduction: University of Toronto (UofT) Pathology residents typically participate in daily hands-on Gross Rounds. These rounds were suspended due to COVID-19 pandemic social distancing restrictions, eliminating a vital component of Pathology education. Objectives: At Mount Sinai Hospital (MSH), we addressed this deficiency by creating an online session to convey gross pathologic features of various organs in a live and interactive manner. Methods: Various configurations were tested for a ‘studio’ set up at MSH grossing lab. Zoom conferencing was used, inviting trainees, Pathologists’ Assistants (PA), and Pathologists across Toronto. A Google poll survey evaluated the effectiveness of the virtual gross rounds. Results: A webcam, microphone, tripod, and 2 computers with monitors and online connectivity are required. Two, socially-distanced, personnel are needed: a ‘producer’ to host the conference and a ‘presenter’ to lead the gross rounds. Zoom polling and chat are utilized for interactivity. The sessions are recorded for archiving. All survey participants (n=15) consisting of pathology residents and PA students rated the video and audio quality highly, with scores of 4.1 and 4.3 (out of 5), respectively. All agreed or strongly agreed that the complexity of specimens was appropriate. Most reported that interactivity accounted for 25-50% of the sessions, with all positively highlighting the poll questions. Discussion: We provide a live gross rounds template with archiving capabilities to supplement pathology education, especially during the COVID-19 pandemic. This pilot initiative will form a larger online education strategy at UofT, with the goal of reaching an even wider community.
Title: Recurrent Soft Tissue Amyloidoma In Morel-lavallee Lesion: Case Report And Review Of Literature
Authors: Gena Ibrahim1, Bret Wehrli MD1, Allison Maciver MD2, Manal Gabril MD1
1Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, Canada.
2Department of General Surgery, Schulich School of Medicine & Dentistry, Western University, Canada.
Abstract: Abstract: Soft tissue amyloidoma is a rare lesion that can be mistaken clinically for a soft tissue sarcoma. We present an unusual case of a recurrent soft tissue amyloidoma and review of the published literature. A 63-year-old male presented with an enlarging left thigh mass of several months duration that was complicated by skin ulceration, eschar, and fluid drainage. MR imaging identified a 13 CC x 9 AP x 6 ML cm, lentiform, well-circumscribed collection in the subcutaneous tissue of the lateral aspect of the left proximal/mid-thigh. A Morel-Lavallee lesion with possible infection was the favored clinical diagnosis. The mass was resected. Histological examination revealed homogenization of the dermal collagen with deposits of amorphous, eosinophilic, Congo red positive, apple-green birefringent material consistent with amyloid. Acute inflammation, histiocytic infiltrates, and necrosis were also present. The blood vessel walls were free of amyloid. Plasma cell neoplasia was not identified. A review of past medical history and previous pathology reports revealed that a left thigh soft tissue mass was resected 17 years previously that consisted of a cyst filled with necrotic debris and small amyloid deposits. This lesion was interpreted as a soft tissue amyloidoma recurrence. Although local resection is curative for amyloidoma, patients must be evaluated for systemic involvement of amyloidosis. Our case showed no systemic disease (e.g. plasma cell dyscrasia) despite the longstanding history of prior excision.
Position: Medical Student
Title: Value Of Liver Biopsy In Anorexia Nervosa-related Transaminitis: A Case Study And Literature Review
Authors: Kyrillos Faragalla1, Jeffrey So2, Pak C. Chan3, Hanlin L. Wang4, Jimin Liu5,6
1. Faculty of Health Sciences, McMaster University, Hamilton, ON;
2. Department of Internal Medicine, Halton Healthcare, Oakville, ON; 3. Department of Lab Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, and LMP, University of Toronto, ON. 4. Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA. 5. Department of Laboratory Medicine, Halton Healthcare, Oakville, ON. 6. Department of Pathology and Molecular Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON.
Abstract: Anorexia nervosa (AN) is a complex eating disorder that affects multiple organs. Liver injury with transaminitis occurs in 63-76% of patients. Liver biopsies are typically not ordered in such cases. We present a patient with severe AN-related transaminitis who underwent liver biopsy and a literature review of similar cases to delineate the clinicopathologic spectrum of liver injury in AN patients. A 19-year-old female with AN was admitted for abdominal pain, with BMI 12.7 kg/m2 and marked transaminitis (ALT, AST >40x the upper limit of normal ULN), yet the liver biopsy was near normal. A Google Scholar search for keywords “anorexia nervosa” and “liver [needle] biopsy” or “autopsy” yielded 35 cases in 22 reports, including one autopsy. Of the 36 cases, including ours, 31 were female, median age 26-year-old, median BMI 12.4 kg/m2. Clinical presentations included severe malnutrition(58%) and hypoglycemic coma(19%). On admission,. Bloodwork showed 21(58%) enzyme levels >15xULN hypoalbuminemia(41%); and elevated INR(74%) and bilirubin(33%). Microscopically, All but one case had near normal liver architecture, 15 cases had glycogen depletion, 8 atrophy,12 cases fibrosis (6/12 AST>10xULN), 8 necroinflammation (5/8 AST>10xULN), and 4 macrovesicular steatosis (2/4 NASH), 5 iron deposition and 2 increased glycogen deposition (1/2 glycogenic hepatopathy). Concurrent etiologies included drug toxicity, Wilson’s disease, and hemochromatosis. In conclusion, AN patients display a wide spectrum of liver histopathology and transaminitis does not correlate with the degree of liver injury microscopically. In persistent AN-related transaminitis, liver biopsy is useful to assess true liver injury and to exclude other potential etiologies.
Title: Monitoring Cytotechnologist-cytopathologist Discrepancy For Non-gyn Cytology: a Useful Method To Enhance Educational Feedback For Cytotechnologists
Authors:Shao Shi Li (1,2), Susan McRae (2), Mariamma Joseph(1,2) 1 Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, Canada 2 Department of Pathology and Laboratory Medicine, London Health Sciences Centre, Canada
Abstract: We describe an objective QA method to analyze cytotechnologist (CT) and cytopathologist (CP) discrepancy data for Non-GYN cytology (Pittsburgh Method). Our objectives were 1) to analyze results of this method for our urine cytology at LHSC and 2) to develop an effective ongoing educational feedback mechanism for CTs on discrepancy cases. Reports of 5942 urine samples (2018-19) were reviewed for CT screening interpretation and CP final diagnoses. Each diagnostic category was assigned a score (0-5) using Pittsburgh Method. Discrepancy (D) is defined as CT minus CP diagnosis. Insignificant Minor Ds, are defined as differences less than +/-2.0 and significant Major Ds are defined as greater than or equal to +/-2.0. Our concordance rate was 95% (5626/5942) and discordance 5% (316/5942) with Minor D 5% (310 cases), and Major D 0.001% (6 cases). Histology follow up available for 61 cases (6 Major D and 55 Minor D) showed HGUC for 4 Major Ds and 31 Minor Ds. This practical QA method can be applied effectively for any Non GYN sample, in an academic or community laboratory. Our results show high concordance rate and minimal Major D for urine cytology. Use of this method would permit the division head and CT supervisor to exercise mutually beneficial and meaningful educational feedback with CTs primarily for overall diagnostic improvement. Once set up, this method may also be used as an optional Non GYN QA performance indicator for Cytotechnologists.
Title: A Rare Case Of Basal Cell Carcinoma With Arterial Invasion
Authors: Minqi Xu1 and Ami Wang1
1. Department of Pathology and Molecular Medicine, Queen’s University, Kingston, Ontario.
Abstract: Basal cell carcinoma (BCC) is the most common type of skin cancer with a very small risk of metastasis in the ranges of 0.0028 to 0.55%. Furthermore, arterial invasion in primary BCC is an extremely uncommon feature. We report a rare case of recurrent BCC post-Vismodegib treatment with arterial invasion. A 78 year old man with extensive skin carcinoma history was diagnosed with BCC in the left posterior neck in July 2018. He was treated with surgical resection and adjuvant Vismodegib, which was discontinued in February 2019 due to hepatic toxicity. A subcutaneous lesion was found at the previous tumour site in June 2020. Pathological examination revealed a recurrent BCC with sclerosing and infiltrative patterns. On the periphery of the tumour, two intravascular tumour thrombi were seen in the lumen of small muscular arteries. There is a third small muscular artery showing tumour cells infiltrating the vessel wall but not within the vascular lumen. Arterial invasion in BCC has not been systemically studied. Although there is no evidence in the literature demonstrating arterial invasion as a precursor of metastatic BCC, we hypothesize it is most likely a poor prognostic factor and a potential link to hematogenous metastasis of BCC. Our case serves as a reminder to actively look for arterial invasion in basal cell carcinoma; this is a feature that is easily overlooked in routine practice, but may convey important prognostic information and treatment implications.
Title: Fatal Secondary Aortoduodenal Fistula Diagnosed With Postmortem Computed Tomography Angiography, A Case Report
Authors: Ariel Gershon 1, Chistopher Ball 1,2, D’Arcy D. Little 3, Andrew S. Williams 1,2
1. Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON; 2. Provincial Forensic Pathology Unit, Ontario Forensic Pathology Service, and Department of Laboratory Medicine and Pathobiology, University of Toronto, ON ; 3. Department of Medical Imaging, University of Toronto, Toronto, ON.
Abstract: Secondary aortoduodenal fistula (AEF), although less rare than its primary form, is an uncommon and rapidly lethal cause of gastrointestinal (GI) bleeding. We report a case of fatal GI hemorrhage in a woman with a remote history of endovascular graft repair of an abdominal aortic aneurysm. Postmortem examination included computed tomography (PMCT) and CT angiography (PMCTA), which revealed ectopic air in the aorta, loss of the fat plane between the aorta and duodenum, and direct extravasation of contrast from the aorta into the duodenum. To our knowledge, this is the first published report of secondary AEF diagnosed by PMCT and confirmed with PMCTA. In conclusion, we propose a set of imaging and pathological criteria by which PMCTA can be used to supplant traditional anatomical dissection in the medicolegal investigation of deaths due to AEF.