Mesenterio

https://www.buzzfeed.com/fionarutherford/no-weve-not-discovered-a-new-organ-in-the-human-body?utm_term=.tfLr0e3r31#.scXqJ3RqR5

Unspected

Cancer Rates Have Dropped 25 Percent in the Past 25 Years http://flip.it/njgS96

Igual a Uruguay

Echa un vistazo al Tweet de @doctormisti: https://twitter.com/doctormisti/status/744191442118127616?s=09

http://www.nature.com/modpathol/journal/v29/n7/full/modpathol201665a.html

Spitz!!

http://www.nature.com/modpathol/journal/v29/n7/full/modpathol201670a.html

Myxofibrosatcoma

Echa un vistazo al Tweet de @RoseannIWu: https://twitter.com/RoseannIWu/status/748958396292927490?s=09

Cancer cells

Echa un vistazo al Tweet de @theNCI: https://twitter.com/theNCI/status/749203256929296384?s=09

Sólido pseudopapilar

Echa un vistazo al Tweet de @marthabpitman: https://twitter.com/marthabpitman/status/748919938228875264?s=09

Myxoid sarcoma fna

Echa un vistazo al Tweet de @RoseannIWu: https://twitter.com/RoseannIWu/status/748959250542657537?s=09

Genética del cáncer de pulmón

Echa un vistazo al Tweet de @NEJM: https://twitter.com/NEJM/status/731454247376654336?s=09

Para quienes interese saber como se trabaja en Anatomía Patológica.

http://www.cancer.org/acs/groups/cid/documents/webcontent/003185-pdf.pdf

Muy interesante!!!

Para leer todos los involucrados en el Cáncer.

https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=50876


Vale la pena recorrer:

https://www.cancercare.on.ca/

COMIENZA EL CURSO DE ANATOMIA PATOLOGICA PARA CCGI 2, FACULTAD DE MEDICINA

CURSO de ANATOMIA PATOLOGICA CCGI2 2015
TEORICOS.
1. Patología tumoral del tracto digestivo. J. Barcia 14 de mayo
2. Patología tumoral del aparato urinario. J.Barcia 21 y 22 de mayo
3. Patología tumoral de piel y partes blandas. J.Barcia 28 y 29 de mayo
4. Patología quirúrgica de las glándulas endócrinas. J.Barcia 4 y 5 de junio
5. Tumores pleuro-pulmonares y mediastinales. J.Barcia 11 y 12  de junio
6. Tumores del sistema nervioso y óculo-orbitarios. R. De Armas 18 y 19 de junio

Se desarrollarán cuatro (4) turnos, dias Jueves y Viernes a las 17 y 20hs, Piso 7 Hospital de Clínicas.

TALLERES CLINICO-PATOLOGICOS
1) Cáncer mamario 25 de junio
2) Cáncer colo-rectal 26 de junio
3) Cancerbronco-pulmonar 2 de julio
4) Nódulo tiroideo 3 de julio

Docente Coordinador-Responsable: Prof.Agdo.Dr. Juan J. Barcia
Equipo Docente:
Prof.Adj. Dr. Phd.Rafael De Armas
Asist. Dr. Javier Cedrani
Ayuds. Br Renzo García y Br Ma. Magdalena Acle.

Ninguna de las actividades previstas es obligatoria, por lo cual no se realizará control de asistencia. Los teóricos se colgarán íntegros en www.juanbarciapathology.blogspot.com junto a links de interés y materiales de estudio complementarios.
Diariamente durante la duracióndel curso se enviarán tweets con información,links, fotos,etc para extender información. @juanbarcia #CCGI2
La evaluación se realizará en el examen final con preguntas múltiple opción. Intentaremos que exista una comunicación fluída via mail (juanjbarcia@gmail.com) y vía Twitter (@juanbarcia).
El volumen de estudiantes que siguen el curso lo estimaremos en base a la concurrencia a las actividades y los seguidores de Twitter, simplemente a efectos de hacer hincapié en el volumen de información presencial u online y ajustar el espacio locativo disponible. A efectos de uniformizar conceptos el texto “oficial” será el “Robbins” 8va o 9a edición. De encontrar el estudiante información discordante con lo que se suministre por los docentes agradecemos se nos indique para subsanar el error o actualizar el contenido del libro.
Las clases que eventualmente deban suspenderse por problemas de disponibilidad de salones se recuperarán los dias 9 y 10 de julio.

Pleural cytology

This cluster of cells, one of few, derived from plaques and nodules in parietal pleura of a 62 yo male.
In situ scrapping of pleural biopsy stained with Methylen blue 1%.
Diagnostic considerations: malignant, non small cell tumor. Difficult subtyping. Some lumen or cytoplasmic vacuolization could be suspected. Nucleoli are ready aparent.
My first impression was of an Adenocarcinoma. Mesothelial origin could not be ruled out.
In permanent sections a poorly diferentiated carcinoma was observed, with isolated microlumen present and some vacuolated cells. However extensive eosinophilic cytoplasm was present.
In IHC slides P63 was strongly positive. Calretinin, CK7, TTF-1 and Napsin A negative.
Without other available antibodies (ie GATA 3, etc)  a diagnosis of secondary SCC or Urothelial carcinoma was rendered.

WHO Lung Cancer Classification 2015.

La World Health Organization se propone publicar en 2015 (primavera boreal) el último libro “azul”sobre la clasificación de tumores pulmonares, pleurales, mediastinales y cardíacos. 

A nivel del cáncer pulmonar está “nueva clasificación” actualiza numerosos conceptos que han evolucionado desde la última publicación de la WHO sobre el tema (2004)e incorpora elementos 

genéticos y moleculares. 

A fines del año pasado se dieron los últimos toques y se hicieron públicas las propuestas de cambio en reuniones en USA y Europa.

En breve postearemos los principales cambios.

Uruguay now. Surgical Pathology in crisis.

In Uruguay, Surgical Pathology (SP) lives one of the worst moments in its history. 

Both public and private practice show marked loss of civil and spiritual values, reduced credibility among colleagues and the general public, internal wars, and very poor salaries or      remunerations. 

In this context, academy has lost its ancient role and few show the desire or motivation enough to engage a position in  the Faculty Departments of SP, thus the influence of the academic places is almost zero, and the students are poorly instructed. 

All elements described above generate a SP of poor quality.

The future is obscure. Leadership is absent and this ship needs a Captain urgently.

Difficult situations in lung nodules frozen sections analysis.

Difficult situations in lung nodules frozen sections analysis.

I have been working in lung pathology for more than 10 years. Frozen sections are a common request from lung surgeons. I have a fairly complete record of the procedures in which I have participated, more than 3000. Reviewing my experince I found four situations particularly difficult to resolve in the intraoperative consultation.

Usually we performed imprint or scrapped preparations cytology stained with Hematoxilyn-Eosin or Methylen Blue 1% solution. If these slides are not conclusive frozen sections of selected samples are prepared and stained with H&E. 

I hope these examples could help others to prevent the mistakes I have commited.

1. Cavitated mass/nodule. TACAR unconclusive. Abscess vs Carcinoma with necrosis. 

First scenario: Incisional biopsy. If fibrotic wall with islands of squamous epithelium and severe inflammation is observed, and no definite atypia of the epithelial component is present a diagnosis of abscess could be rendered. 

That is not correct. This picture does not rule out carcinoma. Frequently, extensively necrosed epidermoid carcinomas are only represented by invasive nests of bland epithelium, that are only focally preserved. Thus, the incisional biopsy could not be representative of the malignant tumor. A negative incisional biopsy should prompt the request of aditional biopsies or the ressection of the whole lesion

Second scenario: Ressection of the whole lesion. A cavited mass filled with granular and purulent material. Wall irregularly thickened, with gelatinous areas. Many samples of the wall are obtained for frozen sections and they show fibrosis, inflammation and squamous epitehlium. Once again hyperplastic changes of the metaplastic epithelium could be inferred with pseudo-invasive patterns. The intense necroinflammation is in concert with an abscess. Thus, diagnosis of lung abscess is rendered.

That is not correct. Extensively necrotic Epidermoid carcinoma coul be present in just few focus of the lesion, and sampling could miss them. Sometimes the embedding of the lesion in toto is the only way to confirm benignancy or malignancy.

2. Similar case. 

The incisional biopsy shows fibrosis, nests and islands of solid squamous epithelium with bland cytology but some nuclear figures alarming, sourrounded by mixed inflamation. Mitosis are  present, and invasion is considered. A diagnosis of Epidermoid Carcinoma is rendered.

That is not correct. Long standing lung abscess develops squamous metaplasia that could be  florid and pseudo-invasive. In episodes of acute inlflammation mitosis and atypia are common in concert with epithelial regeneration. Once again a request for aditional biopsies is mandatory or the whole ressection. Only the wide sampling could be unequivocal in defining malignancy in these cases. 

3. Lung nodule. Cancer is suspected by TACAR. 

Atypical ressection is performed. The pathologist has the entire lesion to analize. A solid, expansive mass, tan coloured is observed. Grossly, carcinoma seems a good diagnosis. Imprints and frozen sections show nests and nodules of large cells with abundant eosinophilic cytoplasm, nuclei are mildly enlarged, with frequent nucleoli. Many cells exhibit high nucleo/cytoplasmic ratio. Necrosis is present. A diagnosis of Epidermoid carcinoma is rendered.

That is not correct. Granulomatous reactions (tuberculosis in this case) could present as solid masses of epithelioid cells, lightly atypical, associated with necrosis. High nucleo/cytoplasmic ratio is frequently observed in the morphologic spectrum of active macrophages, specially when they are monocytes recently recruited. Clues to diagnosis are the abscense of definite atypia and keratinization in a lesion of bland cytology that would be well differentiated.

4. Similar case but now there are extensive areas of necrosis. 

Grossly, such creamy material could be interpreted as keratin. Microscopy show the same aspect as the previous case, but giant cells are present and the creamy material was interpreted as caseum. A diagnosis of tuberculosis is rendered.

That is not correct. Epidermoid carcinoma is frequently associated with extensive keratinization, which in turn could be inflammed. Keratin ellicit giant cell reactions and granulomas when present in the connective tissue. Clues for diagnosis are the presence of groups of epidermoid cells, even with unremarkable atypia, and recognizing masses of keratin as what it is, not necrosis.

In conclusion, for cavited mass lesions of the lung, only the diagnosis of malignancy is reliable in frozen sections. The possibility of a false negative is high, and depends on sampling errors, misinterpretation,etc, and the probability of error is higher in biopsy material. 

In the case of solid lesions with epithelioid cells and necrosis, the possibility of granulomatous infection must be always taken in consideration, but if epidermoide clusters with or without definite atypia are present, and keratin is identified merged with necrosis, carcinoma should bediagnosed. We observed one case of coexistence of tuberculosis and epidermoid carcinoma in the same lesion, an absolutely exceptional situation that merits just for anecdote.

In many cases cytology slides let the observer to make diagnosis, specially if a malignant lesion is present. Negative cytology slides sholud be complemented with frozen sections to rule out malignancy. If the whole slides are negative, diagnosis of benignancy should be made carefully, and limitations of the technich must be comunicated to the surgeon. Grossly malignant lesions should be better treated as malignant if pulmonary function of the patient tolerates wide ressection. Imagenology and clinical impression are rarely wrong in appropiate hands. However, never lost from your focus that first of all you have to think in the patient.

Frozen sections of lung nodules is a widely performed procedure intended to aid the surgeon in taking therapeutic decisions in situ. A benign lesion could be cured with limited lung ressection but on the contrary, malignant lesions need oncologic surgery. Pathologic diagnosis are of prime importance in such context. A surgical pathologist should ideally be specialized in thoracic pathology or, at least, experienced in the field. Difficult situations are uncommon, but when one happens the actuant pathologist must be prepared to give the most accurate possible diagnosis. This paper highlights four of that difficult situations, extracted from our large serie of frozen sections in lung surgery. 

Dentro del 65 Congreso Uruguayo de Cirugía (2014) tendré el gusto y el honor de participar de la Sesión o Mesa Redonda sobre "Cirugía y Peritoneo" coordinada por el Dr. Justino Zeballos.
Miércoles 3 de diciembre de 2014. Hotel Conrad. Punta del Este. Uruguay. 
Visite la página sobre tumores peritoneales en este blog.

Draft, letter to the Editor, Arch Pathol Lab Med

Dear Editor, 

I’ve been dealing with thoracic pathology for 9 years. Mostly in a reference health center specialized in diagnosis and therapy of thoracic disease, either neoplastic or not. In that period I personally signed out thousands of reports and performed thousands of intraoperative consultations. At the beggining therule was to perform frozen sections on any sample provided by the surgeon. However, when I had to go at different distant places where no cryostat was available I started to use Touch Preparation Cytology alone. Perhaps that was the most important moment in my daily practice. The decision of rely diagnosis on a simple, cheap, quick and confident method. After years I eventually abandoned frozen sections and in every case just made TPC. Now Ihave more than 6 years of experience with intraoperative TPC in virtually any organ of the body. Now I could confident say that TPC is the best method for quick intraoperative diagnosis. During these years I perfectioned a procedure that makes me able to render a diagnosis in about 5 minutes, including the grossing of the sample and microscopy analysis.

The technic is as follows:

1. Detailed gross analysis. Mainly to confirm and define the presence of pathology. A gross diagnostic impression must be obtained in concordance with the findings in CT scans and other available imagenologic studies and theopinion of the physician dealing with the case. The area were TPC and scrapping must be performed is carefully selected. Two minutes could be necessary but seldom more than 5 mins (except for large resections)
2. 1 or 2 slides are obtained and fixed in 95° alcohol for 30 secs.
3.Then rinsed in tap water, 10-15 secs.
4. The moisted slides are then exposed to a solution of 1% Methylen Blue for 15 secs.
5.Then wash in water till the excess of colorant dissapear, about 5 secs is enough.
6. Put coverslips.

TPC are ready for examination in less than a minute and a half. At a glance diagnosis could be rendered in less than a minute if you are an experienced pathologist. And that’s all. Minimum cost, light efford and, if properly performed, superb cytologic quality.

Methylene Blue stain shares many of the staining properties of the more traditional Giemsa stain, as both employ the same basic dye.
The nuclear details are sharply delineated: chromatin both disperse or clumped, nuclear envelope profile, nucleoli, mitotic figures.
Poor cytoplasmic stainning is perhaps the negative aspect that could object the orthodox microscopists. Although most cells show a lightly blue hue easilyappreciated, thus the amount of cytoplasm, the relative position of the nuclei and nucleus/cytoplasm ratio could be analyzed.

Another objection that could be emphasized is that TPCs mounted in water are not permanent. The stain vanishes with time an cells become dessecated. Two options are available for eliminate the problem. First, the dessecated slides could be rehydrated and restained with the same procedure described above. The cells were fixed in alcohol thus when adhered to the glass and fixed they will remain unchanged for many years if properly stored (without light, in a fresh and dry container). Alternatively an HE stain could be performed on the former MB stained TPC. I had restained slides after years of storing and results are the same observed previously. Second, after the intraoperative consultation finished, the MB stained slide could be dehydrated,cleared and mounted with permanent medium, but anyway, as happens with Giemsa stain, the dye will vanish in time, so you could restain with HE prior topermanent mount them.

This method is specially suitable for places were the pathologists are not provided with equipment. A very common situation in undeveloped countries. Also when a intraoperative consultation is requested but no pathology lab is present in the health center.

A quick diagnosis and/or quality sample evaluation could be made at the side of the ultrasound guided biopsy or needle aspiration site, or immediately afteran endoscopic biopsy is obtained. Small samples are specially suitable for TPCanalysis. All you need is some slides, a box of cover slips, few drops of Methylene Blue solution, 95° alcohol and water. These items could be boxed in a little plastic bag or container, you could even carry them in your pocket. Remember that both alcohol and water would be found in any surgical room.

I had developed and tested this procedure just because of the context in which I am working in. Anyway, I consider that any worlwide pathologist could found it useful sometime.

Besides, a fast stained TPC could help to an accurate diagnosis as an aid to the most sofisticated technic or perfect frozen section.





Juan J. Barcia MD

Aggregate Professor of Surgical Pathology.Medicine Faculty.Universidad de la Republica.Consulting Pathologist in Thoracic Pathology.ASSE. MSP.Montevideo, Uruguay. 

Scanning EM tejido adiposo