Zi Long Chow¹

¹Pathology Queensland Sunshine Coast University Hospital, Queensland, Australia

Abstract:
Sustainability and climate change is gaining importance in the medical profession. Based on the Lancet Countdown on health and climate change, the healthcare sector is responsible for 4.6% of global greenhouse gas, which makes it the fifth largest emitting “country”. The RCPA has published a recent guideline on “Environmental Sustainability in Pathology Laboratories” in April 2024 and endorsed the joint statement "Working together to achieve sustainable high-quality health care in a changing climate" with 15 other Australasian medical colleges. This review aims to broadly cover issues and solutions relating to Anatomical Pathology, climate change and sustainability. With climate change exacerbating the healthcare system’s challenge of meeting increasing demand, there remain solutions which could bring about positive changes to the status quo through rethinking, reducing, reusing and recycling. Aside from the benefits of reducing carbon footprint, strategies in environmental stewardship can help to cut cost, reduce waste, and insulate from supply shortages. Pathologists and trainees should be aware of how sustainability and climate change can affect their practice. As there is a paucity of studies in the current literature, more studies are required to inform safe and sustainable practices.

Rose-Lynn McCarthy¹, Christina Brown^2,3, Sandra O’Toole^1,3, Timothy Fielder¹, Sunaina Anand¹, Sanjay Warrier^3,4, Wendy A Cooper^1,3,5

¹Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, NSW Health Pathology Camperdown NSW Australia 

²Department of Haematology, Royal Prince Alfred Hospital, Camperdown NSW, Australia

³Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.

⁴Department of Breast Surgery, Chris O’Brien Lifehouse, Camperdown, New South Wales, Australia 

⁵School of Medicine, Western Sydney University, Sydney, NSW, Australia.

 

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytic disease of an undefined progenitor cell. The disease has a myriad of clinical manifestations with diverse organ system involvement, particularly in the long bones as well as the perinephric and periaortic spaces. Histologically, ECD is characterised by a proliferation of mature typically foamy histiocytes in a background of inflammatory stroma. The disease is often driven by BRAF V600E mutations, reported in 54% of cases¹ and can follow a previous diagnosis of Langerhans cell histiocytosis (LCH).

 

We present a case of a 60yo woman with a history of prior duodenal LCH who presented with ECD in the unusual location of the chest wall surrounding breast implants, and initially thought to represent a florid reaction to ruptured implants. The lipid laden foamy macrophages of the disease obscured detection of BRAF V600E expression by immunohistochemistry whilst further molecular testing confirmed a BRAF V600E mutation, leading to the diagnosis of mixed histiocytosis (ECD/LCH). This highlights the importance of considering BRAF V600E molecular testing if ECD is suspected, especially given the history of prior LCH. A positive result can open up treatment options for patients and establish a risk profile for frequency of follow up and survival.

¹ Haroche, J., Charlotte, F., Arnaud, L., et al. (2012). High prevalence of BRAF V600E mutations in Erdheim-Chester disease but not in other non-Langerhans cell histiocytoses. Blood, 120(13), 2700–2703

Jack Naughton¹, Patrick Hosking^1
1Eastern Health Pathology, Box Hill Hospital, Box Hill, Victoria, Australia 

Transformation of CLL/SLL into a more aggressive lymphoma was first described in 1928 by Maurice Richter, and was subsequently coined Richter transformation. Diffuse large B-cell lymphoma (DLBCL) is the most common histological subtype, with transformation into T-cell lymphoma and Hodgkin lymphoma less commonly described. Approximately 9% of patients with untreated CLL/SLL transform into DLBCL¹, while approximately 0.4% transform into Hodgkin lymphoma². Richter transformation is typically characterized by a marked increase in lymphadenopathy at one or more sites (often abdominal) and worsening of B symptoms³. We present the novel case of an 80 year old female with long standing CLL/SLL who presented with severe AKI and hypertension and was found to have a PET avid caecal lesion. Biopsy of this caecal lesion revealed three concurrent lymphomas, CLL and dual Richter transformation into morphologically distinct DLBCL NOS and high-grade B cell lymphoma NOS (HGBCL NOS). 

References:
1. Rossi D, Cerri M, Capello D, Deambrogi C, Rossi FM, Zucchetto A, De Paoli L, Cresta S, Rasi S, Spina V, Franceschetti S, Lunghi M, Vendramin C, Bomben R, Ramponi A, Monga G, Conconi A, Magnani C, Gattei V, Gaidano G. Biological and clinical risk factors of chronic lymphocytic leukaemia transformation to Richter syndrome. Br J Haematol. 2008 Jun;142(2):202-15. doi: 10.1111/j.1365-2141.2008.07166.x. Epub 2008 May 19. PMID: 18492108. 
2. Tsimberidou AM, O'Brien S, Kantarjian HM, Koller C, Hagemeister FB, Fayad L, Lerner S, Bueso-Ramos CE, Keating MJ. Hodgkin transformation of chronic lymphocytic leukemia: the M. D. Anderson Cancer Center experience. Cancer. 2006 Sep 15;107(6):1294-302. doi: 10.1002/cncr.22121. PMID: 16902984. 
3. Mukkamalla SKR, Taneja A, Malipeddi D, et al. Chronic Lymphocytic Leukemia. [Updated 2023 Mar 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470433/

Lavisha S Punjabi¹, Clement Chun-Ho Wu^2,3,4, Samuel Lim Jun Ming²,  Albert Low Su Chong⁵, Tony Lim Kiat Hon^1,4. 

¹ Department of Anatomical Pathology, Singapore General Hospital; ² Department of Gastroenterology, Singapore General Hospital; ³ Division of Gastroenterology, Johns Hopkins Hospital; ⁴ Duke-NUS Medical School; ⁵ Department of Diagnostic Radiology, Singapore General Hospital. 

Mesenchymal tumours involving the pancreas are uncommon, and their subtyping on cytology is challenging. 

A 65-year-old male presented for loss of weight. CT showed an ill-defined mild low density change at the pancreatic head. MRCP showed a 3.4cm solid lesion, T2-w hypointense relative to the pancreas, prompting consideration of leiomyoma or fibromatosis as differentials.

The patient then underwent EUS-FNA. A 3.4cm homogenous iso-echoic mass was visualised and sampled. Smears and cell block showed short spindle cells embedded in fragments of collagenous stroma. The spindle cells showed uniform, ovoid nuclei with granular chromatin. There was no high grade atypia nor necrosis. The spindle cells were positive for STAT6, CD34, and BCL2. The cytological findings are indicative of solitary fibrous tumour (SFT). 

Confirmation with molecular studies is ideal, but was hampered by limited material, prompting careful clinico-radiological correlation. The pancreas is an unusual location for SFT¹, and only rare cases of cytological diagnosis at this site have been reported^2,3. Rarely, other tumours, such as dedifferentiated liposarcoma may co-amplify STAT6, and demonstrate SFT-like morphology; however the small size and the absence of a fat component on radiology rendered this improbable. Hence, the consensus at multi-disciplinary team discussion was for follow-up surveillance imaging. 

References: 

1.     Yavas A, Tan J, Ozkan HS, Yilmaz F, Reid MD, Bagci P, Shi J, Shia J, Adsay V, Klimstra DS, Basturk O. Solitary fibrous tumor of the pancreas: analysis of 9 cases with literature review. The American Journal of Surgical Pathology. 2023 Nov 1;47(11):1230-42.

2.     Rogers C, Samore W, Pitman MB, Chebib I. Solitary fibrous tumor involving the pancreas: report of the cytologic features and first report of a primary pancreatic solitary fibrous tumor diagnosed by fine-needle aspiration biopsy. Journal of the American Society of Cytopathology. 2020 Jul 1;9(4):272-7.

3.     Jones VM, Wangsiricharoen S, Cornea V, Bocklage TJ, Ali SZ, Allison DB. Cytopathological characteristics of solitary fibrous tumour involving the pancreas by fine needle aspiration: Making an accurate preoperative diagnosis in an uncommon location. Cytopathology. 2022 Mar;33(2):222-9.

Alex Wang¹, Anusha Kapoor^1
1Department of Anatomical Pathology, Dorevitch Pathology, Victoria, Australia

Malignant transformation of an ovarian mature teratoma into a primary neuroectodermal tumour is exceptionally rare. It typically presents in young patients with early-stage disease. We present the case of a malignant neuroectodermal tumour arising from an ovarian mature cystic teratoma in a young female. Morphological and immunohistochemical features were consistent with a high-grade glioma. The pathogenesis and molecular drivers of the disease process are poorly understood. This presentation aims to highlight the spectrum of malignant tumours of neuroectodermal origin arising from ovarian teratomas, with an emphasis on morphological, immunohistochemical and molecular characteristics.

Prasad, K^1,2., Horadogoda, D², Penkala,S¹., Zhang, L.¹, Dayal M.R¹

¹School of Science, Western Sydney University, Penrith, NSW, 2751, Australia

²Anatomical Pathology, Nepean Hospital, NSW Health Pathology, Kingswood, NSW, 2751, Australia

Background: Mastectomy specimens represent challenging cases in anatomical pathology, requiring thorough assessment and advanced dissection techniques. The documented decline in anatomical knowledge among medical graduates, coupled with limited hands-on training opportunities, amplifies these challenges^1,2. Relying on direct patient specimens for training highlights critical concerns about educational quality and patient safety.

Objectives: To systematically review educational resources and training tools for pathology trainees, focusing on three-dimensional (3D) models and simulation-based learning approaches for specimen dissection.

Methods: A comprehensive systematic review was conducted using PRISMA guidelines across multiple databases, including MEDLINE, Web of Science, ProQuest, and Scopus. The review examined English-language studies from the past 15 years describing 3D educational tools for anatomical pathology dissection training. From 10,788 initial articles, studies were screened using structured criteria.

Results: While several articles met the criteria, the review revealed a significant gap in practical hands-on resources designed to enhance dissection and macroscopic analysis skills. Existing literature predominantly focused on supplementary case information rather than direct technical training.

Significance: This systematic review identifies critical gaps in current pathology training methodologies and highlights the potential of innovative 3D educational tools to improve specimen handling and assessment practices.

 
References:

1.      Jurjus RA, Lee J, Ahle S, Brown KM, Butera G, Goldman EF, et al. Anatomical knowledge retention in third-year medical students prior to obstetrics and gynecology andsurgery rotations. Anatomical Sciences Education. 2014;7(6):461-8.

2.      Prince KJ, Scherpbier AJ, Van Mameren H, Drukker J, Van Der Vleuten CP. Do students have sufficient knowledge of clinical anatomy? Medical education. 2005;39(3):326-