Fatima Shamsuddin

Detailed answer provided here

What would be your leading diagnosis based on the frozen section?

🔬 Frozen Section Challenge ❄️❄️❄️ 👉 43-year-old female with a 25 cm pelvic-abdominal cystic mass causing bilateral hydronephrosis. MRI favored a malignant ovarian epithelial neoplasm. Intraoperative consultation: Frozen section performed to guide surgical management. #Pathology #Histopathology #FrozenSection #GynecologicPathology #OvarianNeoplasm #Pathologist #PathTwitter #DiagnosticPathology #CancerDiagnosis #TumorPathology

IHC & Frozen

🔍 Frozen Section Challenge – 💡Answer: Ovarian Endometrioid Carcinoma Poll Results • Endometrioid carcinoma – 36% ✅ • Mesonephric-like adenocarcinoma – 35% • High-grade serous carcinoma – 22% • Clear cell carcinoma – 7% 🔎 Histologic Clues in this Case ✔ Complex confluent/back-to-back glandular architecture ✔ Endometrioid-type glands lined by columnar cells with moderate atypia ✔ Foci of squamous differentiation and morular metaplasia ✔ Areas showing mucinous and clear cell change (recognized morphologic variants in endometrioid carcinoma) ✔ Absence of the marked pleomorphism typically seen in high-grade serous carcinoma Immunophenotype ✔ CK7 diffuse positive ✔ ER diffuse strong positive ✔ PR diffuse strong positive ✔ PAX8 positive ✔ WT1 negative ✔ Napsin A negative ✔ p53 wild-type pattern ✔ MMR proteins retained ❓Why Endometrioid Carcinoma? The combination of classic endometrioid morphology, squamous/morular differentiation, diffuse ER/PR expression, WT1 negativity, and wild-type p53 strongly supports endometrioid carcinoma. ⏳ Differential Diagnosis A. High-Grade Serous Carcinoma • Usually WT1 positive, abnormal (mutant-type) p53 staining • More pronounced nuclear atypia and pleomorphism • Squamous differentiation is uncommon B. Mesonephric-like Adenocarcinoma • Usually ER and PR negative or only focally positive; often GATA3 and/or TTF1 positive • Lacks squamous/morular differentiation • Characteristic architectural diversity (tubules, ducts, slit-like spaces) C. Clear Cell Carcinoma • Typically Napsin A and HNF1β positive; usually ER/PR negative • Hobnail cells and classic clear cell architecture predominate • Squamous differentiation is uncommon 🎯 Endometrioid carcinoma is one of the most morphologically diverse ovarian carcinomas and may show squamous, morular, mucinous, secretory, ciliated, oxyphilic, and focal clear cell differentiation. Recognition of these patterns, together with the immunoprofile, is essential to avoid overcalling mimics such as mesonephric-like adenocarcinoma or clear cell carcinoma.   #Pathology #GynPath #GynecologicPathology #OvarianCancer #EndometrioidCarcinoma #Histopathology #DiagnosticPathology #PathTwitter

@Prangan93 Will post the permanent sections with IHC soon, and then hopefully your queries will be answered.

@FatimaShamsPath Please correct me if my thinking is faulty: I’m not seeing back to back glands enough for classical endometriod carcinoma features. That being said, I see a few areas with papillary architecture and the nuclear features are concerning including some that are vesicular

@DrTasnim5 WT1 was not done. P53 and p16 was done on endometrial bx and image is posted in the answer.

@FatimaShamsPath What about p53,p16 and WT1 staining

🔬 A Cytology Lesson: One Marker • Two Histories • Three Primaries !!! 👩‍⚕️ Patient • 72-year-old female with pleural effusion • Initial history provided: Previous h/o anal squamous cell carcinoma and breast carcinoma 🔍 Cytology Findings • Highly cellular specimen • Malignant epithelial cells in clusters and 3D groups • Marked nuclear atypia • Occasional vacuolated cytoplasm 🧪 Initial Cell Block IHC ✅ BerEP4 positive ❌ Calretinin negative ✅ CK7 positive ❌ CK20 negative 🎯 Diagnostic Approach Based on Available History • TTF1 → to exclude primary lung adenocarcinoma • p63 → to assess squamous differentiation • TRPS1 → to evaluate possible breast origin 📋 Results ❌ TTF1 negative ❌ p63 negative ✅ TRPS1 patchy positive ⚠️ The Pitfall With a history of breast carcinoma and a CK7+/TRPS1+ profile, metastatic breast carcinoma seemed highly likely. 🔄 The Turning Point • TRPS1 positivity was only patchy • Additional clinical information was obtained • Histologic correlation was performed 🧩 The Missing History The patient also had a recently diagnosed endometrial malignancy with frozen pelvis and extensive local spread, a crucial piece of information that was not initially available. 🧬 Further Workup ✅ PAX8 positive - favor mullerian ❌ GATA3 negative - point against breast cancer 📌 Final Interpretation Metastatic Müllerian carcinoma, with correlation favoring high-grade serous carcinoma. 💡 Take-Home Messages ✔️ TRPS1 is a useful marker, but not entirely specific for breast carcinoma. ✔️ Patchy TRPS1 positivity can be seen in Müllerian serous carcinomas and other non-mammary tumors. ✔️ Never interpret immunostains in isolation. ✔️ Morphology + Clinical History + Imaging + Histology Correlation = Accurate Diagnosis. ✔️ Always question a result that does not perfectly fit the overall picture. 🏆 Lesson Learned 💎 The most important diagnostic tool in this case was not TRPS1—it was the missing clinical history. #Cytopathology #PleuralFluid #DiagnosticPitfall #TRPS1 #BreastPathology #PathologyPearls #Cytology #ClinicopathologicCorrelation #PathTwitter #MedEd #LearningFromCases

⚠️ Apologies for the intentionally incomplete history in the original post. The aim was to demonstrate how even a useful marker such as TRPS1 can be misleading when interpreted without the full clinical context. 🔬 No IHC marker is perfect. 📋 Clinical history matters. 🧩 Correlation matters. The full diagnostic journey and take-home lessons are shared below 👇

🗳️ What is your leading diagnosis based on the available history + immunophenotype?

Pleural fluid cytology. 👉 75-year-old female with: ▫️History of advanced anal squamous cell carcinoma (treated with chemoradiotherapy in 2012) ▫️History of breast carcinoma on follow-up   #PathTwitter #Cytopathology #Surgpath #TRPS1

Endometrial biopsy of the same case #histocytocorrelation

🔎 Histo-cyto correlation! 👉 74-year-old female with hematuria and bladder mass ⚓️ Urine cytology showed features suspicious for High-Grade Urothelial Carcinoma (HGUC) with: 🔬 Hyperchromatic crowded cell clusters 🔬 Single scattered atypical cells 🔬 Marked pleomorphism, high N:C ratio 🔬 Irregular nuclear membranes & coarse chromatin 💎 Biopsy confirmed High-Grade Papillary Urothelial Carcinoma showing fused/complex papillae, loss of maturation, diffuse cytologic atypia, and numerous mitoses. A nice histocytologic correlation case highlighting the importance of urine cytology in detecting HGUC. #PathTwitter #Cytopathology #Uropath #Surgpath #UrineCytology #HGUC #UrothelialCarcinoma #Histopathology #MedEd #Pathology

Answer

🧵 Case: Histo–Cyto Correlation! 74-year-old female; Bladder biopsy and Urine cytology. What is your diagnosis? #PathTwitter #Cytopathology #UrineCytology #GUPath #Histopathology #Pathology #MedEd #Surgpath

Indeed an inspiring journey and vision. It was truly wonderful attending the IAC meeting in Sweden this January and having the opportunity to meet you and so many distinguished faculty members from across the world. The exchange of knowledge, ideas, and experiences were invaluable. What stood out most was how approachable and encouraging all the office bearers and senior experts were — making all of us feel like equal members of one global cytology community. Looking forward to seeing IACytology and the cytology community grow even further.

“Dreams do come true.” During the recently concluded Asian Federation of Cytology Societies (AFCS) inaugural congress in Hong Kong, many people asked me how all of this happened - how we achieved such success so quickly. My answer was simple: it was neither quick nor easy. It took many years of vision, persistence, and collective effort. Over the last 25 years, I have made more than 75 trips to East Asia. During those visits, I repeatedly recognized the need for a consortium where national cytology societies across Asia could pool their talent, resources, and expertise, while also supporting smaller and resource-limited countries. The ultimate vision was to create a unified annual congress in which every Asian national society could participate, alongside distinguished faculty from other regions of the world, including the United States and Europe. About 10 years ago, I began discussing this idea with many Asian friends and colleagues. While everyone supported the concept enthusiastically, there was understandable skepticism about how such an ambitious vision could ever become reality. Years passed before I finally received a lucky break. About three years ago, I presented a rough plan to my close friends, Drs. Gary Tse and Bob Osamura, both of whom became instrumental in supporting the founding of AFCS. The name “AFCS” itself was finalized after I discussed the concept with Dr. Danijela Vrdoljak-Mozetic, secretary-general of the EFCS, as the mission statements of the two federations were remarkably aligned. It then took nearly a year of countless WhatsApp calls by me with many individuals across Asia, seeking support to enlist their national organizations as companion societies under the AFCS umbrella. Once our list grew to 20 countries, I felt the time was right to formally announce the launch of AFCS at the International Congress of Cytology in Florence, Italy in May 2025. That became a pivotal moment in our journey. Soon afterward, the executive council was established. Upon my strong recommendation, Bob Osamura was approved as the first President of AFCS, and Gary Tse as the Secretary-General, with Hong Kong selected as the federation headquarter and venue for the historic inaugural congress. Dr. Jamal Musayev from Baku designed the eye-catching insignia. The orange color symbolizes the warmth and optimism of Asia, with rays of sunlight reflecting hope, unity, and a bright future. Those who attended the recent congress witnessed firsthand the extraordinary work accomplished by Dr. Gary Tse and his remarkable team. Congratulations to them - and to everyone who contributed their time, effort, and expertise to this historic success. As the congress concluded, I finally allowed myself a quiet sigh of relief. A dream that once seemed distant had finally come true. As Ryūnosuke Satoro, a Japanese poet and philosopher so beautifully said: “Individually, we are one drop. Together, we are an ocean.” Today, with more than 20 national societies united together, we have created that mighty ocean - visible, collaborative, impactful, and full of promise for the future of cytopathology across Asia and beyond. @cytopathology @IACytology @CytologyEFCS @JM_CytoBox @MozeticV