Clinical Corelation and Pathologi

7/28/2019 Clinical Corelation and Pathologi

1/50

CORRELATION OF

CLINICAL ANDPATHOLOGICAL

DIAGNOSIS OF NEOPLASM


2/50

1. Clinical Degree of Malignancy

Doubling time

The shorter the D.T. the

higher degree of malignancy


3/50

Low Degree ( > 4 Months )

Moderate ( 24 Months )

High ( < 2 Month )


4/50

Table 1. Mean volume doubling time in weeks.

In Tannock IF and Hill R. The Basic Science of Oncology. 2nd ed.

Mac Grow Hill Inc. Health Professionals Division. New York 1992,

p. 155

NO TUMOR TYPEMEAN DOUBLING TIME

( in weeks )

1 Primary Lung Cancer

- Adenocarcinoma 21

- Squamous cell carc. 12

- Anaplastic carc. 11

2 Breast Cancer

- Primary 14

- Lung metastasis 11

- Soft tissue metastasis 3


5/50

3 Colon Rectum

- Primary 90

- Lung metastasis 14

4 Lymphoma

- Lymph node lesion 6

5 Lung Metastasis of

- Testis carcinoma 4

- Childhood tumours 4

- Adult sarcoma 7


6/50

2. Pathological Degree of Malignancy

Grade of cell differentiation( Pleomorphism, Mitotic Index,

Necrotic Cell ) The higher grade of differentiation, the

lower degrees of malignancy, and thebetter prognosis

Lymphoid infiltration ( Medullary Ca,Invasive Ductal Ca. )


7/50

I. Clinical Manifestation

A. As Primary Tumor

Plaque

Nodule tumor

Erosion ulcer

Nodular ulcerativa

No Special form


8/50

B. As Metastasis Lungs

Lymph Node

Liver

Brain

Bone


9/50

C. As Complication(s) of

the Disease Bleeding from the ulcer or

abnormal bleeding or discharged

from the body orifice.

Obstruction of the body canal

Malfunction or disfunction of theorgan ( Organ Failure )

Infection


10/50

Fracture

Cachexia

Hormonal Disturbance Serotonin Syndrome

Cushing Syndrome Hyperparathyroidisme


11/50

II. Diagnostical Procedures

A. Clinical Procedure in Diagnosis

Taking History ( anamnesis )

Chief complain

The rate of growth of the tumor

Aetiology and risk factorCauses of delay

Treatment carried out elsewhere andresult


12/50

Performing physical examination

Endoscopy

Radiological examination

Laboratory examination


13/50

B. Pathological Procedures in

Diagnosis TakingBiopsi

Cytology materialOperative specimen

Process for microscopic slide

Evaluating

Histological slide is only small

sample of tissue


14/50

Error in sampling / processing

error interprestation

The pathologist have be informedthe clinical presentation and

corelate to microscopic finding.


15/50

Microscopic Inconsistency

Clinical PictureReevaluateRebiopsi

Pathologic ReportMorphology

Behaviour

Grade of Differentiation

Angioinvasion


16/50

Report of Operative

Form

Size

Angioinvasi

Radically of Operation

Involvement of Lymph Node


17/50

III. Diagnosis of Cancer

The Base of Diagnosis

1. Clinical Diagnosis

A lesion ( plaque, tumor, ulcer whichgrows progressively

Sign of infiltration

The presence of sign of metastasis toregional lymph nodes or to remote

organs


18/50

2. Pathological diagnosis

3. Validity of diagnosis

4. Certainly of diagnosis


19/50

IV. Correlation of Clinical and

Pathological Diagnosis

1. Clinical Presentation and

Histologic Type

2. Clinical Diagnosis and

Pathological Diagnosis

Benign tumor

Tumor of uncertain behaviour

In situ cancer

Invasive cancer


20/50

3. Degree of MalignancyClinical Degree of

MalignancyPathological Degree of

Malignancy


21/50

Table 2 : Clinical characteristics of benign

and malignant neoplasm

NO CHARACTE

-RISTICS

BENIGN

TUMOR

MALIGNANT

TUMOR

1 Form Regular Irregular

2 Border Sharply demarcated No or demarcated

3 Capsule Present No or pseudo-capsule

4 Vascular Normal Hyper & neo-vascular

5 Temperature Normal Hyperaemia


22/50

6 Necrotic Seldom Often

7 Ulceration Seldom Often

8 Recurrent Seldom Often

9 Growth Progressive,

slow,expansive,

local and limited

Progressive,vast,

expansive & invasive and

unlimited

10 Metastasis No Yes and Often

11 Organs Function Seldom disturb Often disturb

12 Systemic effect Seldom Often

13 Fatal Outcome Seldom Nearly always


23/50

2 In situ neoplasma D00 to D09 C00/2 to C80/2

3 Benign neoplasma D10 to D36 C00/0 to C80/0

4 Ulcertain or unknown

behaviourD37 to D48 C00/1 to C00/1

2 Non - neoplasm - -


24/50

It is important to keep in mind when to

think about early cancer. We have to think

about cancer when discover :1. One or more of the 7-danger signal of

cancer CAUTION :

C = Change in bowel or bladder habit A = A sore that does not heal

U = Unusual bleeding or discharge

T = Thickening or lump in the breast or else where

I = Indigestion or difficulty in swallowing

N = Nagging cough or hoarseness


25/50

Table 3 . Clinical Diagnosis of Tumor

NO TYPE OF TUMOR ICD

X ICD - 0

1 Neoplasm C00 to D48 C00 to C80

1 Malignant C00 to C97 C00/. to C80/.

1 Primary C00 to C75 C00/3 to C77/3

2 III defined C76 C76/3

3 Secondary C77 to C79 C00/6 to C80/6

4 Unspecified

/unknown primaryC80 C80/9

5 Lymphoid C81 to C90 C77/3

6 Hemopoitic C91 to C96 C42/3

7 Multiple primary C97 -


26/50

2. Tumor in a high risk group : old age,family history, post radiation, immune

compromised.

3. The present of small lesion ( plaque,tumor, erossion ) fit no to the clinical

criteria of benign lession.


27/50

Table 4. Pathologic characteristic of

neoplastic cells

NO CHARACTERISTICSBENIGN

TUMOR

MALIGNANT

TUMOR

1 Cell structure Typical Atypical

2 Vascular Normal Increased

3 Necrotic / Ulceration Rare Often


28/50

4 Cancer cells

- Nuclear / Cytoplasm ratio

- Nuclear structure

- Mitosis

- Anaplastic

Normal

Normal

Rare

No

Approaches 1

Pleomorphic and

polychromatic

Often and atypical

Present with grade of

differentiation

5 Intercvellular space Normal Loss

6 Polarisation Regular Irregular


29/50

7 Cell infiltration No Present

8 Capsule Present No or present of

pseudocapsule

9 Ultrastructure

- Nuclear membrane

- Mitochondria

- Endoplasmic reticulum

- Golgy apparatus

Normal

Normal

Normal

Normal

Often irregular

Sometime aberrant

Present of free RNA

particles

Often consist of

microvesicles

10 Metastasis No Present and often


30/50

Table 5. Grade of differentiation of squamous cell

carcinoma according to Broder.

The present of pearl formation indicate welldifferentiated

Grade I II III IV

Differentiation Well Moderately Poorly Undiffe-

rentiated

Mature Cell ( % ) > 75 50- 75 25 - 50 < 25


31/50

Table 6. Grade of differentiation of adeno carcinoma of the

breast according to Bloom and Richardson.Mitotic index per 10 HPF = High Power Field

Grade I II III IV

Differentiation Well Moderately PoorlyUndiffe-

rentiated

Tubular Formation ( % ) > 75 50 - 75 25 - 50 25


32/50

Table 7. Nottingham modification for grading of breast cancer

Grade I II III

Total score 3 - 5 6 - 7 8 - 9

Score 1 2 3

Pleomorphism > min moderate High

Mitotic index 0 - 5 6 - 10 > 10 PPF

Tubular formation ( % ) > 75 10 - 75 < 10


33/50

Table 8. Grade of differentiation of soft tissue sarcoma

Grade I II III

Total score 3-4 5-6 7-9

Score 1 2 3

Cell differentiation Similar to

mature cells

Moderately

diff.

Undiffe-

rentiated

Necrotic cells (%) no < 50 > 50

Mitotic index 0 - 9 10 - 19 > 20


34/50

Table 9. Degree of Validity Diagnosis

NONON MICROSCOPIC

EXAMINATION

MICROSCOPIC

EXAMINATION

1 Clinical Only Cytology or Hematology

2 Clinical Investigation Histology of Metastases

3 Surgical ExplorationHistology of Primary

Tumor

4Biochemical /

Imunological TestAutopsy


35/50

The higher the degree diagnostic methodsemployed, the more valid is the diagnosis

CFactor The higher the degree of

C-Factor the more certain is the diagnosis


36/50

Table 10. Degree of Certainty of Diagnosis

No Methods of Diagnostic

C1Evidence from standard diagnostic means (e.g. physical

examination, standard radiography, endoscopy for

tumours of certain organs )

C2

Evidence obtained by special diagnostics means (e.g.

radiographic imaging in special projections,

tomography, CT-scan, USG, lymphography,

angiography, scintigraphy, MRI, endoscopy with biopsyor cytology )


37/50

C3Evidence from surgical exploration, including biopsy

and cytology

C4Evidence of the extent of disease following definitive

surgery and pathological examination of rescted

specimen

C5 Evidence from autopsy


38/50

Table 11. Correlation of clinical presentations and

pathological findings

NoClinical

PresentationPathological Findings

1 Skin retraction Infiltration of cancer cells to the

ligament of Cooper

2 Skin fixation Infiltration of cancer cells to the skin

3 Peau d orange

Infiltration to the subcutaneous or

cutaneous lymphatic vessels causing

obstruction of lymphatic flow

4 UlcerationNecrotic tissues and infiltration of

cancer cells to the skin


39/50

5 Satellite nodule of the

skin

Metastasis to the skin

6 Mastitis carcinomatosa Widespread of skin and subcutaneous

infiltration

7Restriction the of

tumor mobility to the

pectoral muscle

Infiltration of cancer cells to the pectoral

fascia

8Restriction of the

shoulder joint mobility

Infiltration of cancer cells to the pectoral

muscles

9 Lymphoedema of the

arm

Extensive obstruction of lymphatic flow

due to metastasis into the lymph nodes and

lymph vessels of the axilla


40/50

Clinical Diagnosis and Pathological

Diagnosis

1. Benign Tumor :

Well defined

Smooth surface

Without sign of infiltration

Located superficial in an organs


41/50

Small tumor

Look like benign tumor

Does not located in well known

organs for benign tumor

Does not necessary benigntumor


42/50

Clinical manifestation of malignanttumor in early stage practically the same

of benign tumor

The probability of the malignant alwayskeep in mind

Consider : Epidemiologic data, the age,

risk, site of tumor


43/50

2. Tumor of uncertainty behaviour

Clinical and pathological examination

benign

Treated as benign RecurrentMalignant

Granulosa, Leydig, Sertoli, Thymoma.

Of boderline malignancy


44/50

3. Insitu Cancer

Only a few cancer : Bowen disease

Paget disease

NIS of the cervix

No in soft tissue sarcoma

Clinically : Plaque or erosion

Final diagnoses based on pathological

examination < 5% of the clinically diagnosis is right


45/50

4. Invasive Cancer

A. Early Cancer

Difficult to diagnose clinically

No sign of infiltration

Presentation nearly similar to benign tumor

Clinically diagnosis Tumour of the

Path exam Discover diagnosis

< 10% clinical diagnosis is right Correlation clinical diagnosis and early cancer

is poor


46/50

B. Advanced Cancer

Sign of infiltration and metastaes Clinical diagnosis is not difficult

> 70% clinical diagnosis is right

Correlation between clinical diagnosis and

pathological diagnosis is good

Recurrent tumor where the former diagnosis

was benign, the current diagnosis is a big

problem Epidemiological data for certain degree may

help to solve the problem


47/50

Some problems (no correlation

between the clinical and the

pathological diagnosis) :

Clinically manifestation as benign

neoplasm, but pathological as malignant,

such as : Juvenile Melanoma

Clinically manifest as malignant tumor,

but pathologically as benign : Papillary

Adenoma of Thyroid


48/50

Tumor of the first or second presentation

clinically and pathologically look like asbenign but if treated as benign usually after

a periode of TME will recur : Deep seated

fibroma and lipoma Clinical and pathological presentation as

benign tumor, but demonstrate metastases

to regional node or even remote organ :Thyroid Adenoma


49/50

No primary tumor can be discovered, butpresents with pathologically proven

metastases to one or more organs

MUO (Metastases of Unknown Origin)


50/50

Terima Kasih

Documents

Clinical Corelation and Pathologi