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I have the opportunity to talk about renal cell tumors,

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I have the opportunity to talk about renal cell tumors,

which is one of my favorite topics.

Feel free to reach out afterwards if you have any questions or anything like that.

And of course, live, I'll be happy to answer any questions here. So first,

let's just start off with sort of an introduction about renal

cell tumors kind of go through in a pattern-based approach by some of the more common patterns,

clear cell, papillary, and eosinophilic,

and then talk about some other tumors.

What's important about renal tumor pathology?

Well, I think nowadays we might be asked to do more with less.

That is, we might be asked to diagnose renal mass biopsies more regularly or perhaps biopsies from metastatic sites of renal cancer.

And it may be tricky with just a very small visualization of the tumor.

is a trend toward less aggressive management of renal tumors.

So if you have a very small renal mass,

there may be consideration for surveillance.

And so the diagnosis that we make in a biopsy could be relevant for surveillance.

And then there's increasing recognition that renal cell cancer is more than one disease.

And trying to divide them into clear cell or non-clear cell types may be important for management purposes,

especially when you have metastatic renal cancer.

Clinicians would like to know ideally if we have a clear cell or non-clear cell tumor.

So here's just an example of what might happen based on a renal mass biopsy.

So say a renal mass biopsy is performed,

this is from a publication in the Journal of Urology several years ago.

If the histology is benign,

like for example angiomyelipoma, then nothing further needs to be done.

But if you have a very low-risk tumor like a chromophobe renal cell carcinoma or a low-grade papillary renal cell carcinoma,

this algorithm suggests that active surveillance would be reasonable.

As you have kind of intermediate risk tumors,

like a clear cell of grade 1 to 2 or a higher grade papillary tumor,

the algorithm kind of figures that depending on tumor size,

if you have a very small size,

that may be amenable to active surveillance.

But as the size is larger,

that may be a candidate for surgery.

And then very high-risk tumors are kind of automatically a candidate for surgery,

such as tumors that are grade three or urothelial carcinomas or comatoid or unclassified renal cell carcinomas.

So just an example of what might happen based on renal mass biopsy.

The way I kind of approach it is that if a renal mass biopsy is being done,

it probably means that the clinicians are thinking of doing something different other than the routine resection of the renal mass.

And so I should think about sort of the risk of the tumor

and try to do my best to classify it into a specific box,

whether it's a high or low risk tumor.

So if you have a patient that perhaps is elderly with multiple comorbidities,

that may be an indication for surveillance.

So a biopsy might be done considering that surveillance would be undertaken for a patient who has perhaps not an extreme...

We're going to do some sneaky cancers in gastric biopsies.

Everyone's favorite topic.

Puts hair on your chest.

I have no conflicts to report and so today in this discussion we're going to focus on like two broad categories.

Benign mimics of gastric cancer in biopsy samples.

Talking about macrophages and epithelial mimics.

And then carcinomas that simulate benign conditions both diffuse type and tubular type carcinomas.

So let's start off with benign mimics of carcinoma.

The major situation in which you're going to come up against benign repair type changes

that simulate neoplasia are in the context of chemical gastropathy with ulcers.

What happens is you'll, and there are a lot of different scenarios,

the epithelial cell atypia related to repair,

gastric xanthomas or macrophage responses to ruptured epithelial cells,

sloughed mucus neck cells that simulate signet ring cell carcinoma,

tissue processing artifacts, and mucosal ischemia.

So you'll remember from a few days ago,

chemical gastropathy, we see a diffuse alteration in the epithelial cell morphology

and architecture without much inflammation to explain those So the pits are elongated

and they're lined by cells that are cytoplasmically depleted with a nuclear enlargement and scattered mitotic activity.

Most of the time what you can appreciate is

that there's maturation of this epithelial cell atypia as you move to the surface of the mucosa.

You can get into trouble when there are erosions in areas of extreme repair because that induces even more cytologic abnormalities,

as you can see here.

A few clues that you're dealing with a benign process.

You see superficial fragments that do show maturation,

and the overall proliferation respects the boundaries within the mucosa,

so you'll see that there is a lobular architecture overall with preserved bundles of smooth muscle cells and vessels permeating the mucosa.

Higher power, you can see some of that cytologic atypia over here.

In general, I would say don't make a diagnosis of low-grade dysplasia

and be very careful about a carcinoma diagnosis in the setting of chemical gastropathy with an erosion.

My colleague Liz Montgomery some time ago published a paper talking about repair type atypia in Barrett esophagus

and in the gastric mucosa and described what she calls the four lines of maturation in benign epithelium or non-neoplastic epithelium.

And I think it's a helpful thing to keep in mind

when you're approaching repair-type changes in the stomach and in the distal esophagus.

And what she was talking about is when you have In this presentation,

I will talk about breast pathology in the area of genomics.

Molecular testing has been increasingly used in breast cancer diagnosis and treatment.

In this presentation, I will use some case examples to illustrate how we use molecular testing to help us with tumor classification,

diagnosis, and treatment.

As a surgical pedologist, we don't have to personally do molecular testing,

but it's important to know using it as a tool to help us interpreting difficult cases.

So for two more classification,

we talk about this in our triple negative breast cancer presentation.

Certain special histological subtypes of carcinoma,

breast carcinomas, have characteristic somatic genomic alterations.

In difficult cases, we could use these alterations to help us to confirm the diagnosis.

For example, I know cystic carcinoma has maybe NFIB rearrangement or maybe L1 rearrangement, maybe amplification.

I don't always do this testing.

If histologically is consistent, I'll go ahead and make the diagnosis.

But in difficult cases, we can do in situ hybridization,

sequencing analysis, or recently We have been using immunoskeministry as a surrogate to detect the genomic alteration.

Another tumor is this one,

secretory carcinoma, has characteristic ETV6 N-TRAC fusion.

Again, we can use FISH or sequencing analysis or immunoskeministry for PANTRAC to confirm the diagnosis if histologically it's not classic,

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it's not definitive.

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This is another tumor with unique mutation profile we talk about.

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Tall cell carcinoma with reverse polarity has unique IDH2 R172 hotspot mutation.

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This can be detected by sequencing analysis or immunosupportism chemistry using mutation specific immunosupportism chemistry assay.

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So I don't want to repeat too much.

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I'll move on to case examples to show how we use molecular testing,

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helping us in diagnosis in difficult cases.

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So this case, a patient was a 40-year-old woman with rapidly growing mass in the breast,

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almost 5 centimeters at presentation.

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had a core biopsy diagnosis, proceeded with mastectomy.

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I'll show you some images from her mastectomy specimen.

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This is the...

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