Paediatric Pathology

Paediatric Pathology

Dr Rajeev Shukla Consultant Paediatric Pathology Department of Paediatric and Perinatal Pathology Alder-Hey Children’s Foundation Trust Liverpool

Q1 A neonate who failed to pass the meconium presents with fever, diarrhoea and abdominal distension. A rectal biopsy is taken to reach a diagnosis. Which of the following is true.

A.

A full thickness biopsy is essential for the diagnosis

B.

The biopsy should be put in formalin immediately after the procedure to ensure good fixation for Acetylcholinesterase staining.

C.

Presence of thick nerve fibres in the biopsy excludes the diagnosis.

D.

Presence of ganglion cells in appropriate sample excludes the diagnosis under consideration.

E.

Biopsy should be taken at muco-cutaneous junction.

Clues

• Failure to pass meconium – Hirschprungs disease – Meconium ileus (Cystic fibrosis) – Intestinal atresia • Fever, diarrhoea and abdomenal distension – NEC is known to complicate HD

Hirschsprung disease (HD) • Aganglionosis of a portion of intestinal tract • Enteric nervous system development involves migration of neural crest cells into the bowel wall.

• The migration is cephalad to caudad.

• In HD, there is arrest of migration at some point before reaching the anus

Types of aganglionosis

(A,B, C – Classical Hirschsprung’s disease)

Short segment

Ultra-short segment

Total colonic

Total

intestinal

Hirschsprung disease (HD)

• Aganglionosis leads to functional obstruction and intestinal dilatation proximal to the affected zone.

• The migration in both Meissner submucosal and Auerbach myenteric plexuses happens simultneously.

• Examination of submucosal biopsy is sufficient for the diagnosis.

• There is a physiologic hypoganglionic zone at sphincter site near the muco-cutaneous junction. Biopsy of this site is not appropriate for the diagnosis of HD

Hirschsprung disease (HD)

• In the affected segment – The ganglion cells are absent – There is hyperplasia of cholinergic nerve fibres. This can be detected by Acetylecholinesterase histochemistry.

– AChE staining can only be done on frozen sections.

SUCTION RECTAL BIOPSY in HD Frozen section (H&E): •

absence of ganglion cells

•

large number of thick nerve bundles in submucosa (if present)

Ganglion cells

Hirschsprung’s disease

Normal control

SUCTION RECTAL BIOPSY in HD AcetylCholinEsterase/AChE stain: • increased number and thickness of AChE+ nerve fibres in stroma of lamina propria & muscularis mucosae () • numerous thick AChE+ nerve bundles in submucosa (*)

*

*

Q4 A neonate who failed to pass the meconium presents with fever, diarrhoea and abdominal distension. A rectal biopsy is taken to reach a diagnosis. Which of the following is true.

A.

A full thickness biopsy is essential for the diagnosis

B.

The biopsy should be put in formalin immediately after the procedure to ensure good fixation for Acetylecholinesterase staining.

C.

Presence of thick nerve fibres in the biopsy excludes the diagnosis.

D.

Presence of ganglion cells in appropriate sample excludes the diagnosis under consideration.

E.

Biopsy should be taken at muco-cutaneous junction.

In a suspected case of HD which one immunohistochemistry stain you would ask for on a rectal biopsy ?

NSE NFP

Calretenin MUC 1 MUC5

Calretenin positive fibres are absent in HD

Calretenin IHC is done on formalin fixed tissue It is not reliable if the sample is frozen.

Many centres have stopped doing AChE

Calretenin in control (normal)

Q2. An abdominal tumour from a 3 month old infant shows a small round blue cells with focal rosettes. In places the background is fibrillary (neuropil). Which of the following features of this tumour is associated with poor prognosis A.

Age under <1 y

B.

Hyperploidy

C.

Presence of many ganglion cells

D.

N-myc gene amplification

E.

Underlying malformation of Kidney.

Clues • Abdomenal tumour in an infant • Small round blue cells • Rosettes and neuropil

NEUROBLASTOMA

Prognosis contd.

Age

Differentiation

MKI

Prognostic group

Survival

< 1.5 years

Any

<200

Favourable

84%

>200

Unfavourable

4.5%

<100

Favourable

84%

>100

Unfavourable

4.5%

Undifferentiated

Any

Unfavourable

4.5%

Any

Any

Unfavourable

4.5%

1.5 - 4 years

>5 years

Differentiated

Shimada et al 1984

Prognostic factors • • • • •

Age: <1.5 y (good) Histological classification MKI N Myc status Staging: 90% in stage 1 to 2.4% in stage4 Exception is stage 4S (Mets in liver, skin, and or bone marrow but NOT bone)

INPC classification 1999 • Neuroblastoma (Schwannian stroma poor NT) – Undifferentiated – Poorly differentiated – Differentiating • Ganglioneuroblastoma nodular (Composite schwannian stroma rich/ dominant and stroma poor NT)

• Ganglioneuroblastoma intermixed (Schwannian stroma rich NT) • Ganglioneuroma (Schawannian stroma dominant NT)

– Maturing – Mature

Prognosis contd.

• • • • •

Flowcytometry DNA pattern -Diploid tumors Loss of 1p Gain of 17q Trk B expression N-myc amplification: • 25% of cases • One of the most important prognostic marker • FISH or PCR

• Increased CD44 expression- favourable • Trk (A&C) gene expression – favourable

Q2. An abdominal tumour from a 3 month old infant shows a small round blue cells with focal rosettes. In places the background is fibrillary (neuropil). Which of the following features of this tumour is associated with poor prognosis

A. B. C. D.

Age under <1 y Hyperploidy Presence of many ganglion cells N-myc gene amplification

E. Underlying malformation of Kidney.

N Myc FISH

Q 3. A baby girl born prematurely at 33 gw is found to have generalised oedema and nephrotic range proteinuria at day 2 of life.

The placenta was large. The kidney biopsy showed striking ectasia of proximal and distal tubules. The glomeruli were normal.

What is the most likely diagnosis?

A.

Diffuse mesangeal sclerosis type congenital nephrotic syndrome

B. Finnish type congenital nephrotic syndrome.

C. TORCH infection D. Congenital HIV infection.

E. Focal segmental glomerulosclerosis

Clues • Congenital • Nephrotic syndrome • Large placenta • Ectasia of tubules • Normal glomeruli

Congenital nephrotic syndrome Causes (onset <3m of life)  Congenital infections  Toxoplasmosis (mesangial proliferative)  Syphilis (membranous glomerulopathy)  Genetic syndromes  Diffuse mesangeal sclerosis • associated with Denys –Drash syndrome • isolated  Congenital nephrotic syndrome of Finnish type (CNF)  Epidermolysis bullosa (FSGS).  Other  Lupus nephritis  Idiopathic: MCD, Membranous ;FSGS

Q3. A baby girl born prematurely at 33 gw is found to have generalised oedema and nephrotic range proteinuria at day 2 of life.

The placenta was large. The kidney biopsy showed striking ectasia of proximal and distal tubules. The glomeruli were normal.

What is the most likely diagnosis?

A.

Diffuse mesangeal sclerosis type congenital nephrotic syndrome

B. Finnish type congenital nephrotic syndrome.

C. TORCH infection D. Congenital HIV infection.

E. Focal segmental glomerulosclerosis

Finnish nephropathy • Gene involved : NPHS1; Chromosome 19 • Gene product: Nephrin • Poor prognosis • Does not respond to steroids or other immunosupressives.

Diffuse mesangial sclerosis

Finnish nephropathy

Delayed onset; several weeks to 12 months

Early onset; usually in utero

Placenta usually normal

Large placenta, malpresentation Low birth weight

Severe hypertension and Progression is slow; rapid progression to Hypertension is a late renal failure feature Mesangial sclerosis is a feature.

Secondary tubular ectasia and cysts develop.

Tubular cysts and mild mesangial hypercellularity.

Mesangial sclerosis develops over a period of time.

Q4. An autopsy done on a 8 month old child revealed Pneumocystis carinii pneumonia. He was also noted to have abnormal facies, very small thymus gland and small ventricular septal defect.

The review of clinical records revealed that he had tetany at one hour of life.

Since then he had multiple episodes of respiratory infections. Which of the following mechanisms, best explains the clinical features.

A. abnormal development of the pharyngeal arches and pouches.

B. Failure of maturation of B cells into plasma cells.

C. Lack of adenosine deaminase D. Acquisition of maternal HIV infection at delivery

E. Failure of differentiation of PreB cells into B cells.

Clues • Immunodeficiency (multiple episodes of respiratory infections and infection by unusual organsim i.e Pneumocystis carini) • Small thymus

• VSD (congenital heart disease) • Tetany- Hypoparathyroidism

Di George Syndrome – Synonyms / related disorders • 22q11 deletion syndrome • Velocardiofacial syndrome.

– Example of T cell immunodeficiency – Traditionally described to be failure of 3rd and 4th pharyngeal pouch development.

– Defects involving the first to sixth pouches are known to occur

– 3 and 4th pharyngeal pouch give rise to parathyroid , thymus, some of the clear cells of thyroid and ultimobranchial body.

Di George Syndrome – Clinico-pathological hallmarks • Hypoplasia or aplasia of Thymus- T cell deficiency • Hypoparathyroidism- Tetany • Congenital defects of heart and great vessels • Abnormal facies • 90% of these cases show deletion involving 22q11 gene.

– At box family of transcription factor involved in the development of branchial arch and the great vessels

Q2 An autopsy done on a 8 month old child revealed Pneumocystis carinii pneumonia. He was also noted to have abnormal facies, very small thymus gland and small ventricular septal defect.

The review of clinical records revealed that he had tetany at one hour of life.

Since then he had multiple episodes of respiratory infections. Which of the following mechanisms, best explains the clinical features.

A. abnormal development of the pharyngeal arches and pouches.

B. Failure of maturation of B cells into plasma cells.

C. Lack of adenosine deaminase D. Acquisition of maternal HIV infection at delivery E. Failure of differentiation of PreB cells into B cells.

Which of the following is true about Primary immunodeficiency • Failure of B cell maturation to plasma cells is seen in common variable immunodeficiency

• Most of the X linked Hyper IgM syndromes are T cell disorders • Adenosine deficiency is seen some cases of severe combined immunodeficiency.

• Failure of maturation of Pre-B cells results in Bruton agammmaglobulinemia.

• All of the above

Robbin’s

Which of the following is true about Primary immunodeficiency • Failure of B cell maturation to plasma cells is seen in common variable immunodeficiency

• Most of the X linked Hyper IgM syndromes are T cell disorders • Adenosine deficiency is seen some cases of severe combined immunodeficiency.

• Failure of maturation of Pre-B cells results in Bruton agammmaglobulinemia.

• All of the above

Q5. A baby was delivered at 31 gw by emergency caesarean section as mother had severe pre-eclampsia. The Apgar scores were 5 and 6 at 1 and 5 min but within 1 hour she experienced severe respiratory distress and dies despite resuscitative measures. The lung histology at autopsy showed atelectasis and alveolar hyaline membranes. Which of the following conditions best accounts for this finding A.

Foetal anemia

B.

Congenital toxoplasmosis

C.

Immaturity of lungs

D.

Oligohydramnios

E.

Maternal toxaemia

Clues • • • •

Premature Neonatal respiratory distress Atelectasis Hyaline membranes on histology

• Hyaline membrane disease

Q5. A baby was delivered at 31 gw by emergency caesarean section as mother had severe pre-eclampsia. The Apgar scores were 5 and 6 at 1 and 5 min but within 1 hour she experienced severe respiratory distress and dies despite resuscitative measures. The lung histology at autopsy showed atelectasis and alveolar hyaline membranes. Which of the following conditions best accounts for this finding A.

Foetal anemia

B.

Congenital toxoplasmosis

C.

Immaturity of lungs

D.

Oligohydramnios

E.

Maternal toxaemia

Pathogenesis LACK OF SURFACTANT

ATELECTASIS HYPOXIA

Increased capillary permeability

Epithelial necrosis

Exudation of fluid into alveolar ducts HYALINE MEMBRANE

Which of the following does not increase the risk of Hyaline Membrane Disease ?

A. Prematurity B. Maternal diabetes C. Twins D. Caesarean sections without trial of labour E . Infants with prenatal stress

Which of the following does not increase the risk of Hyaline Membrane Disease ?

A. Prematurity B. Maternal diabetes

C. Twins D. Caesarean sections without trial of labour E . Infants with prenatal stress

Pathology typical of prematurity • Respiratory: Hyaline Membrane Disease (HMD) Emphysema (including interstitial) Pneumothorax, Broncho-Pulmonary Dysplasia (BPD), Pulmonary Haemorrhage • Cardio-vascular Myocardial Ischemia & Infarction, Persistent Foetal Circulation (PDA)

• CNS

Germinal Matrix Haemorrhage/GMH & Intraventricular Haemorrhage/IVH Periventricular Leucomalacia/PVL,

• Gastro-intestinal : Necrotizing entero-colitis (NEC), strictures • Infections / Septicaemia

• Retinopathy • Hypothermia/Hypoglycaemia/Jaundice/Osteopenia

Lung pathology – premature infants

• Hyaline membrane disease • Chronic lung disease of prematurity (‘New’ bronchopulmonary dysplasia) • Massive pulmonary haemorrhage

Hyaline membrane disease • Histology – Uniform alveolar collapse

– Dilated airspaces seen are alveolar ducts and terminal bronchioles – These are lined by eosinophilic membranes.

– Membranes are composed of necrotic alveolar lining cells, amniotic fluid constituents and fibrin – Yellow membranes- incorporation of unconjugated bilurubin

Q6. A 9 year old boy died of septicaemia. Pseudomonas aerugenosa was cultured from the blood and sputum before the death. There is a history of diarrhoea with bulky foul smelling stool for last 5 years.

The autopsy findings included necrotizing pneumonia, mucus plugging of the pancreatic ducts with exocrine pancreatic atrophy. Which of the following is most likely to explain the findings in this child.

• • • • •

A. Galactose -1 –Phosphate uridyltransferase deficiency B. LDL receptor gene mutation C. Phenylalanine hydroxylase deficiency D. Impaired epithelial cell transport of chloride ion.

E. Common variable immunodeficiency.

Q6. A 9 year old boy died of septicaemia. Pseudomonas aerugenosa was cultured from the blood and sputum before the death. There is a history of diarrhoea with bulky foul smelling stool for last 5 years.

The autopsy findings included necrotizing pneumonia, mucus plugging of the pancreatic ducts with exocrine pancreatic atrophy. Which of the following is most likely to explain the findings in this child.

• • • • •

A. Galactose -1 –Phosphate uridyltransferase deficiency B. LDL receptor gene mutation C. Phenylalanine hydroxylase deficiency D. Impaired epithelial cell transport of chloride ion.

E. Common variable immunodeficiency.

Cystic fibrosis • Cystic fibrosis (CF) is the most common lethal inherited disease.

• Autosomal recessive disorder • Most carriers of the gene are asymptomatic.

• • CF is a disease of exocrine gland function that involves multiple organ systems and chiefly results in chronic respiratory infections, pancreatic enzyme insufficiency.

• Pulmonary involvement occurs in 90% of patients surviving the neonatal period. End-stage lung disease is the principal cause of death.

Which of the following is not a feature of Cystic fibrosis ?

A.

Recurrent pulmonary infections

B.

Pancreatic insufficiency

C.

Steatorrhea

D.

Intestinal obstruction

E.

Male infertility

F.

Hepatic cirrhosis

A.

Mental retardation

Which of the following is not a feature of Cystic fibrosis ?

A.

Recurrent pulmonary infections

B.

Pancreatic insufficiency

C.

Steatorrhea

D.

Intestinal obstruction

E.

Male infertility

F.

Hepatic cirrhosis

A.

Mental retardation

Which of the following is not true about Cystic fibrosis?

A.

Defect in epithelial chloride channel protein

B. Mutations of CFTR gene on chromosome 7 C. There is increased resorption of sodium and chloride in the sweat duct.

D. There is reduction in chloride secretion to the lumen of respiratory tract.

Which of the following is not true about Cystic fibrosis?

A.

Defect in epithelial chloride channel protein

B. Mutations of CFTR gene on chromosome 7 C. There is increased resorption of sodium and chloride in the sweat duct.

D. There is reduction in chloride secretion to the lumen of respiratory tract.

Q.7. A neonate died at few hours of life after being born by C section done for markedly enlarged abdomen which interfered with delivery.

The autopsy showed bilateral ,markedly enlarged cystic kidneys .

The cut-surface had sponge like appearance with elongated cysts at right angles to the cortical surface.

The liver on histology showed ductal plate malformation with mild portal fibrosis.

What is the most likely primary diagnosis?

A. Autosomal recessive polycystic kidney disease

B. Autosomal dominant polycystic kidney disease C. Multicystic dysplastic Kidney disease

D. Medullary sponge kidney E. Nephronophithisis

Autosomal recessive polycystic kidney disease

Clinical presentation of ARPKD is highly variable

Up to 50% of affected neonates die of pulmonary hypoplasia

Longer-term survivors frequently develop portal hypertension, esophageal varices, and hypersplenism from periportal fibrosis.

Elongated cysts at right angles to the cortical surface

Q.7. A neonate died at few hours of life after being born

by C section done for markedly enlarged abdomen which interfered with delivery.

The autopsy showed bilateral ,markedly enlarged cystic kidneys . The cut-surface had sponge like appearance with elongated cysts at right angles to the cortical surface.

The liver on histology showed ductal plate malformation with mild portal fibrosis. What is the most likely primary diagnosis?

A. Autosomal recessive polycystic kidney disease B. Autosomal dominant polycystic kidney disease C. Multicystic dysplastic Kidney disease D. Medullary sponge kidney E. Nephronophithisis

Which of the following is not true about Autosomal dominant polycystic kidney disease (ADPKD) ?

Also called adult PKD It may occur in infancy and childhood In paediatric age group may show prominent glomerular cysts.

May also show cysts in liver, pancreas and seminal vesicles.

Ductal plate malformation / hepatic fibrosis is never seen Cysts are of variable size and round rather than elongated.

ADPKD ADPKD Also Also called called adult adult PKD PKD It may It may occur occur in in infancy infancy and and childhood childhood In In paediatric paediatric age age group group may may show show prominent prominent glomerular glomerularcysts. cysts.

May May also also show show cysts cysts in in liver, liver, pancreas pancreas and and seminal seminal vesicles. vesicles.

Ductal Ductal plate plate malformation malformation / liver / liver involvement involvement is is never never seen seen Ductal Ductal plate plate malformation malformation can can bebe seen seen in in ADPKD ADPKD and and some some other other disorders disorders Cysts Cysts are are of of variable variable size size and and round round rather rather than than elongated. elongated.

Embryogenesis of bile ducts.

Johnson C A et al. J Med Genet 2003;40:311-319

Examples of the ductal plate malformation and cystic changes in the liver and kidney for a range of congenital fibrocystic disorders.

Johnson C A et al. J Med Genet 2003;40:311-319

Which of the following is not true about Multicystic dysplastic kidney disease ?

A. It is usually unilateral

B. It is the most common cause of renal mass in neonate C. It is usually not associated with multisystem syndromic abnormality D. It should be distinguished by diffuse dysplasia which is bilateral and often a component of syndromes.

E. Patent ureter should be present for definitive diagnosis.

F. Morphologically dysplasia is seen as lobar disorganisation, immature mesenchyme , cysts and chondroid islands.

A. It is usually unilateral

B. It is the most common cause of renal mass in neonate

C. It is usually not associated with multisystem syndromic abnormality

D. It should be distinguished by diffuse dysplasia which is bilateral and often a component of syndromes.

E. Patent ureter should be present for definitive diagnosis.

Ureter and pelicalyceal system is obstructed or atretic

F. Morphologically dysplasia is seen as lobar disorganisation, immature mesenchyme , cysts and chondroid islands.

Which of the following is not true about Medullary Sponge Kidney ?

Congenital cystic dilatation of terminal collecting ducts in medullary pyramids.

Normal size of the kidneys or only mild enlargement

Common cause of renal failure in first decade of life.

Urolitheasis and UTI are common presentation.

Medullary Sponge Kidney Congenital cystic dilatation of terminal collecting ducts in medullary pyramids.

Normal size of the kidneys or only mild enlargement

Common cause of renal failure in first decade of life.

Usually asymptomatic

Urolitheasis and UTI are common presentation.

Which of the following is not true about Nephronophthesis ?

– Cysts predominantly at cortico-medullary junction.

– Kidney size is normal or decreased.

– It is autosomal recessive with early onset of renal failure as opposed to Medullary cystic disease complex which is autosomal dominant with late onset renal failure.

– It is due to a defect in collagen type IV – Histology is characterised by tubular and glomerular cysts – Tubulo- interstitial inflammation is prominent

– Cysts predominantly at corticomedullary junction.

– Kidney size is normal or decreased.

– It is autosomal recessive with early onset of renal failure as opposed to Medullary cystic disease complex which is autosomal dominant with late onset renal failure.

– It is due to a defect in collagen type IV It is a ciliopathy; Collagen IV abnormality is seen in Alport syndrome.

– Histology is characterised by tubular and glomerular cysts – Tubulo- interstitial inflammation is prominent

Match the following……

ARPKD ADPKD Multicystic dysplasia Diffuse cystic dysplasia Nephronophthisis Medullary sponge Kidney

Match the following……

ARPKD - D ADPKD- C Multicystic dysplasia - A Diffuse cystic dysplasia - B Nephronophthisis- E Medullary sponge Kidney - F

Which of the following sarcoma does not involve EWS gene (Ch22) translocation ?

Ewings sarcoma

Clear cell sarcoma DSRCT Myxoid Chondrosarcoma Alveolar soft part sarcoma

Molecular pathology of sarcomas: two major classes 1. Sarcomas with specific reciprocal translocations and relatively simple karyotypes • • •

•

approx. 1/3 of all sarcomas 15 different sarcoma types with over 25 different translocations fusion genes: aberrant chimeric transcription factors (most) or aberrant kinases (some) biology: transcriptional deregulation or aberrant signaling

2. Sarcomas with complex unbalanced karyotypes and no specific translocations • •

approx. 2/3 of all sarcomas biology: genetic gains & losses, chromosomal instability, telomere dysfunction

Pathologic genetic rearrangements in human cancers: a family tree Translocations

Balanced

Promoter Substitution

Unbalanced

Gene Fusion

Chimeric Transcription Factor

Deregulated gene expression

Loss of Tumor Suppressor

Chimeric Tyrosine Kinase

Deregulated growth signaling

Gain of Oncogene

Major fusion genes in sarcomas: biological overview Sarcoma type

Translocation

Fusion gene

Transcriptional Deregulation

Aberrant Signaling

Ewing sarcoma

t(11;22)

EWS-FLI1

X

t(21;22)

EWS-ERG

X

Clear cell sarc.

t(12;22)

EWS-ATF1

X

Myxoid LPS

t(12;16)

TLS-CHOP

X

Alveolar rhabdomyosarcoma

t(2;13)

PAX3-FKHR

X

t(1;13)

PAX7-FKHR

X

DSRCT

t(11;22)

EWS-WT1

X

Extr. myx. CS

t(9;22)

EWS-CHN

X

Synovial sarc.

t(X;18)

SYT-SSX1,2

X

DFSP

t(17;22)

COL1A1-PDGFB

X

Cong. FS

t(12;15)

ETV6-NTRK3

X

IMT

t(2p23)

ALK fusions

X

End. str. sarc.

t(7;17)

JAZF1-JJAZ1

X

ASPS

t(X;17)

ASPL-TFE3

X

Low grade MFS

t(7;16)

FUS-BBF2H7

X

Pericytoma

t(7;12)

ACTB-GLI

X

Which of the following sarcoma does not involve EWS gene (Ch22) translocation ?

Ewings sarcoma t (11,22) t (21,22) Clear cell sarcoma t (12,22) DSRCT t(11,22) Myxoid Chondrosarcoma t (9,22) Alveolar soft part sarcoma t (X, 17)

EMQ1 A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

1. Multiple intra- abdominal masses in a 16-year-old male.

Small round cells showing positivity for EMA,CK (globoid),NSE, desmin and WT1.

The tumour shows (11; 22) translocation.

OPTIONS A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

1. Multiple intra- abdominal mass in a 16-year-old male.

Small round cells showing positivity for EMA,CK (globoid),NSE, desmin and WT1.

The tumour shows (11; 22) translocation.

A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

2. A polypoid vaginal mass in an 11-month old female showing dense zone of undifferentiated tumour cells immediately beneath the epithelium (Cambium layer)

OPTIONS A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

2. A polypoid vaginal mass in an 11-month old female showing dense zone of undifferentiated tumour cells immediately beneath the epithelium (Cambium layer)

OPTIONS A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

K. Botryoid Rhabdomyosarcoma

Rhabdomyosarcoma (RMS)

• the most common soft tissue tumour in childhood with • peak incidence in the first decade

International Classification of RMS I. Superior prognosis

Botryoid RMS Spindle cell RMS

II. Intermediate prognosis

Embryonal RMS

III. Poor prognosis

Alveolar RMS Undifferentiated RMS

IV. Unknown prognosis

RMS with rhabdoid features

Superior prognosis RMS Botryoid RMS- subtype of e-RMS in vagina, urinary bladder • extends beneath the mucosa, separated by compressed layer of tumour cells – ‘cambrium layer’ Spindle cell variant RMS – with better prognosis, primarily in the paratesticular region (‘paratesticular’ RMS)

Overview of 2013 WHO Classification • 12 phenotypic categories, including 3 new ones (nerve sheath, GIST, undifferentiated sarcoma) • 127 entities • 4 categories of biologic potential • FNCLCC preferred grading system

WHO Biologic Potential Categories • Benign: lipoblastoma

• Locally aggressive: desmoid

• Rarely metastasizing (< 2%) infantile fibrosarcoma inflammatory myofibroblastic tumor

• Malignant: rhabdomyosarcoma synovial sarcoma

3. A 4- year-old male showing macrosomia, hemi hypertrophy and exomphalus presents with an abdominal tumour.

Histology showed a triphasic tumour with epithelial, mesenchymal and blastemal elements.

OPTIONS A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

3. A 4- year-old male showing macrosomia, hemi hypertrophy and exomphalus presents with an abdominal tumour.

Histology showed a tumour with epithelial tubules, mesenchymal tissue and areas of undifferentiated small blue cells.

OPTIONS A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

Wilms’ tumour/ Nephroblastoma

Nephroblastoma = Wilms’ tumour (WT) • Most common genito-urinary cancer in childhood – 1:8000 children • Represents 80% of all renal tumours • Mean age 36 months • 98% below 10 years • 10% of WT develop in dysmorphic syndromes like: WAGR, Beckwith-Wiedemann syndrome etc.

Primary Renal Tumours of Childhood Tumours

Wilms’ tumour, favourable (FHWT) Anaplastic Wilms’ (AnaWT) Mesoblastic nephroma Clear Cell Sarcoma (CCSK) Rhabdoid Tumour (RT) Miscellaneous Lymphoma Neurogenic tumours Angiomyolipoma Renal carcinomas

Relative Percentage

80% 4% 5% 4% 2% 5%

Classification • • • • •

Nephroblastic Tumours (Congenital) Mesoblastic Nephroma Clear Cell Sarcoma Rhabdoid Tumour Renal epithelial tumours of childhood Papillary RCC Renal medullary carcinoma Renal tumour associated with Xp11.2 translocation

• Rare tumours Ossifying renal tumour of infancy Angiomyolipoma

4. A left sided abdominal tumor from an infant feature small round blue cells which show following immunophenotype.Desmin -, myogenin,- CD99-, CD45-, NB84+, NSE+

OPTIONS A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

4. A left sided abdominal tumor from an infant feature small round blue cells which show following immunophenotype.Desmin -, myogenin,- CD99-, CD45-, NB84+, NSE+

OPTIONS A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

5. A fore arm tumour from a 12 year old child shows sheets of small round cells without fibrosis. The tumour cells are Myo D1 positive and show translocation t(2:13)

OPTIONS A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

5. A fore arm tumour from a 12 year old child shows sheets of small round cells without fibrosis. The tumour cells are Myo D1 positive and show translocation t(2:13)

OPTIONS A. Wilms tumour B. Clear cell sarcoma of the Kidney C. Ewings/ PNET D. Pancreatoblastoma E. Desmoblastic small round cell tumour F. Pleomorphic rhabdomyosarcoma G. Neuroblastoma H. Synovial Sarcoma I. Alveolar rhabdomyosarcoma J. Embryonal rhabdomyosarcoma K. Botryoid Rhabdomyosarcoma L. Epitheliod sarcoma M. Large cell lymphoma N. Melanoma O. Fibrosarcoma

Poor prognostic RMS Alveolar RMSt(2;13) (q35;q14) in 75% or t(1;13)(p36;q14)

• result in chimeric transcript factor PAX3/7-FKHR activated oncoprotein dysregulates muscle differentiation • consists of poorly differentiated round-oval tumour cells • divided by collagenous sepatae into ‘alveolar’ structures with • central loss of cohesion amongst cells Solid variant a-RMS lacks alveolar pattern entirely, consisted of densely packed groups of tumour cells with no fibrosis Pleomorphic RMS – very rare in infant and children

Reticulin

EMQ2 • Defination of terms used in the study of errors in morphogenesis.

Options

1. It results from secondary destruction of an organ or body region that was previously developing normaly

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Etiology of Congenital anomalies Types of problems in morphogenesis

Poor formation of tissue

Malformation or malformation sequence

Unusual forces on normal tissue

Deformation or deformation sequence

Breakdown of normal tissue

Disruption or disruption sequence

Options

1. It results from secondary destruction of an organ or body region that was previously normal

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Disruption A morphological defect resulting from the external breakdown of, or an interference with an originally normal developmental process.

Disruption

Amniotic band sequence

Deformation • Bending out of shape of usually normally developed structures due to – excessive extrinsic pressure – intrinsic inability of to resist deforming forces of normal extrinsic pressure. (Arthrogryposis)

Deformation An abnormal form, shape or position of the part of the body caused by external (mechanical or other) forces.

Deformation

Options

2. These are result of primary errors of morphogenesis or intrinsically abnormal developmental process

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Options

2. These are result of primary errors of morphogenesis or intrinsically abnormal developmental process

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Malformation A morphological defect of an organ, part of an organ or a larger region of the body resulting from an intrinsically abnormal developmental process (genetic) Normal Development

Malformation

Options

3. A constellation of congenital anomalies believed to be pathologically related and that can not be explained on the basis of single, localized , initiating events.

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Multiple CA – terminology & definition 1.

2.

3.

4.

Syndrome (SY) – recognisable pattern of multiple anomalies with casually related aetiology (which is diverse) – Down’s Sy, Meckel-Gruber Sy, Sequence (SE) – pattern of multiple anomalies derived from single known or presumed prior anomaly/mechanical factor = causing ‘chain event’ – Potter/Olygoamnios Sequence Association (AS) – non-random occurrence in two or more individuals of multiple anomalies not known to be a polytopic field defect, Sy or Se – VATER Association Complex (CO) – ADAM Co – Amniotic Deformities, Adhesions, Mutilations

Meckel’s Syndrome • Encephalocele • Polydactily (postaxial) • Cystic Kidneys

Trisomy 18 (Edward’s Sy) • Holoprosencephaly (alobar)

• Proboscis • Cyclopia

Options

3. A constellation of congenital anomalies believed to be pathologically related and that can not be explained on the basis of single, localized , initiating events.

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Multiple CA – terminology & definition 1.

2.

3.

4.

Syndrome (SY) – recognisable pattern of multiple anomalies with casually related aetiology (which is diverse) – Down’s Sy, Meckel-Gruber Sy, Sequence (SE) – pattern of multiple anomalies derived from single known or presumed prior anomaly/mechanical factor = causing ‘chain event’ – Potter/Olygoamnios Sequence Association (AS) – non-random occurrence in two or more individuals of multiple anomalies not known to be a polytopic field defect, Sy or Se – VATER Association Complex (CO) – ADAM Co – Amniotic Deformities, Adhesions, Mutilations

Deformation- Potter sequence Etiology heterogeneous

Pathogenesis uniform

Renal agenesis

Foetal Compression

OR Urethral atresia

Potter facies Oligohydramnios

Chronic leakage of amniotic fluid

Phenotype

Abnormal position of hands and feet

Pulmonary hypoplasia Respiratory insufficiency

Options

4. Anomalies resulting as a result of complete absence of an organ and its primordium .

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Options

4. Anomalies resulting as a result of complete absence of an organ and its primordium .

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Options

4. Anomalies resulting as a result of complete absence of an organ and its primordium .

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Anomalies resulting as a result of complete absence of an organ and its primordium .

Absence of an organ but owing to failure of the developmental anlage to develop

Absence of opening usually of a hollow visceral organ such as intestine or trachea

Options

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Options

4. In context of malformation, this term describes abnormal organisation of cells in a tissue.

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Options

4. In context of malformation, this term describes abnormal organisation of cells in a tissue.

• • • • • • • • • • • • •

Malformation Syndrome Sequence Dysplasia Disruption Agenesis Atresia Deformation Hypoplasia Hypertrophy Inflammation Aplasia Minor anomaly

Dysplasia An abnormal organisation of the cells - the morphologic result involves abnormal process of histogenesis (tissue structure).

Dysplasia

BONUS QUESTIONS

Which of the following is true for CIC-DUX 4 Sarcoma ?

1.

2.

3.

4.

5.

6.

7.

Undifferentiated small cell sarcoma More atypical features than typical EWS/ PNET Show focal or multifocal CD99 positivity.

Positive for WT1 Negative for EWS translocation.

Characterised by t (4, 19) All of the above

BONUS QUESTIONS

Which of the following is true for CIC-DUX 4 Sarcoma ?

1.

2.

3.

4.

5.

6.

7.

Undifferentiated small cell sarcoma More atypical features than typical EWS/ PNET Show focal or multifocal CD99 positivity.

Positive for WT1 Negative for EWS translocation.

Characterised by t (4, 19) All of the above

Which of the following is not true ?

1. INI 1 is normally expressed in all nucleated cells.

2. Renal and extra renal Rhabdoid tumours are negative for INI-1 3. Loss of INI1 expression usually associated with deletion or mutation of the INI1 gene on 22q11.2 4. Germline INI1 mutations associated with sporadic schwannomatosis 5. Epithelioid hemangioendothelioma show loss of INI 1 expression.

Which of the following is not true ?

1. INI 1 is normally expressed in all nucleated cells.

2. Renal and extra renal Rhabdoid tumours are negative for INI-1 3. Loss of INI1 expression usually associated with deletion or mutation of the INI1 gene on 22q11.2 4. Germline INI1 mutations associated with sporadic schwannomatosis 5. Epithelioid hemangioendothelioma show loss of INI 1 expression.

Which of the following is true about decidual vasculopathy 1. Results from abnormal / incomplete remodeling of the spiral arteries.

2. Observed in placentas from pre-eclamptic pregnancies as well as several collagen-vascular and in those with evidence of growth restriction.

3. Lesions vary from non-necrotic, non-transformed decidual arterioles to early fibrinoid necrosis of vessel walls and late atherosis.

4. Acute atherosis is morphologically seen as fibrinoid necrosis with subendothelial lipid-laden macrophages 5. All of the above

Which of the following is not true about decidual vasculopathy 1. Results from abnormal / incomplete remodeling of the spiral arteries.

2. Observed in placentas from pre-eclamptic pregnancies as well as several collagen-vascular and in those with evidence of growth restriction.

3. Lesions vary from non-necrotic, non-transformed decidual arterioles to early fibrinoid necrosis of vessel walls and late atherosis.

4. Acute atherosis is morphologically seen as fibrinoid necrosis with subendothelial lipid-laden macrophages 5. All of the above

Which of the following is true about “villous dysmaturity / delayed villous maturation” 1. Proportion of cases are associated with diabetes.

2. Placenta is usually large for gestational age.

3. Terminal villi may be hypervascular and edematous with reduced numbers of syncytial knots.

4. It is associated with late fetal hypoxia and IUD 5. All of the above.

Which of the following is true about “villous dysmaturity / delayed villous maturation” 1. Proportion of cases are associated with diabetes.

2. Placenta is usually large for gestational age.

3. Terminal villi may be hypervascular and edematous with reduced numbers of syncytial knots.

4. It is associated with late fetal hypoxia and IUD 5. All of the above.

Which of the following is not a feature of fetal vascular malperfusion ?

A. Thrombosis of chorionic plate vessel.

B. Avascular villi C. Villous stromal‐vascular karyorrhexis (VSK) D. Perivillous fibrin deposition E. Intramural fibrin deposition, chorionic plate vessel

Which of the following is not a feature of fetal vascular malperfusion ?

A. Thrombosis of chorionic plate vessel.

B. Avascular villi C. Villous stromal‐vascular karyorrhexis (VSK) D. Perivillous fibrin deposition E. Intramural fibrin deposition, chorionic plate vessel

Which of the following is not a feature of Maternal vascular malperfusion?

A . Infarct B. Increased syncytial knotting C. Villous agglutination D. Chorionic plate vessel ectasia E. Distal villous hypoplasia

Which of the following is not a feature of Maternal vascular malperfusion?

A . Infarct B. Increased syncytial knotting C. Villous agglutination D. Chorionic plate vessel ectasia E. Distal villous hypoplasia

Which of the following findings indicate fetal inflammatory response ?

A. B. C. D. E.

Subchorionic abscess Villitis of unknown etiology Inflammation of chorion and amnion Inflammation of chorionic plate vessel Inflammatory infiltrate in umbilical vessel wall.

Which of the following findings indicate fetal inflammatory response ?

A. B. C. D. E.

Subchorionic abscess Villitis of unknown etiology Inflammation of chorion and amnion Inflammation of chorionic plate vessel Inflammatory infiltrate in umbilical vessel wall.

Maternal and fetal inflammatory response

VUE (non infectious) is considered an allo-immune response

Good luck !