Specialist & Consultant Anatomic Pathology oral assessment prep

Knowledge: The honest diagnosis is a mucinous neoplasm of at least borderline type, with invasion not excluded. Large mucinous tumours are heterogeneous, and sampling error is the main reason frozen section under-calls them; permanent sections need about one block per centimetre of tumour. In the WHO classification, expansile invasion of 5 mm or more defines carcinoma, while smaller foci are microinvasion within a borderline tumour. Metastasis from the appendix or gastrointestinal tract must be considered, particularly with bilateral, smaller or surface tumours. Frozen section is least accurate in the borderline category, where a proportion is upgraded on paraffin.

Management: I would examine the specimen myself and freeze one more block from any solid area if time allows. I would phone the surgeon personally, confirm two identifiers and say: mucinous tumour, at least borderline, invasion cannot be excluded, definitive typing needs permanent sections. I would state clearly that this result alone does not justify removing the uterus and right ovary in a young woman. Unilateral salpingo-oophorectomy with washings, omental biopsy, appendix assessment and inspection of the right ovary keeps fertility options open. I would record the diagnosis, time and surgeon's name in the laboratory system. Afterwards I would sample extensively and use CK7, CK20, SATB2 and PAX8 if metastasis remains possible. I would present the final report at the gynaecological oncology MDT, where completion surgery can be planned if invasion is confirmed.

Ethics and communication: My role is to give an accurate answer with its uncertainty, not to make the surgical decision or offer false certainty. Removing fertility on an over-called frozen section would be serious, irreversible harm. Surgery must stay within the consent she gave before theatre, in line with Cabinet Resolution No. 40 of 2019. If the final diagnosis differs, I would issue a supplementary report and phone the surgeon.

Reference: WHO Classification of Tumours: Female Genital Tumours (5th ed, 2020); Rosai and Ackerman's Surgical Pathology (11th ed, 2018)

Knowledge: Invasive lobular carcinoma is a recognised cause of false-negative core biopsy because discohesive single cells mimic stromal or inflammatory cells. A benign result from a BI-RADS 4 lesion is radiology-pathology discordant and should have prompted repeat biopsy or MDT discussion. Error in surgical pathology usually combines cognitive slips with system weaknesses, such as no mandatory correlation or second review. A second consultant should confirm the revised diagnosis. Her treatment now depends on fresh biopsies of the mass and nodes with ER, PR and HER2.

Management: Today I would ask a senior colleague to review the original slides. Once confirmed, I would issue an amended report that keeps the original text visible, states the new diagnosis and explains the amendment. I would phone the surgeon and send written notice so it cannot be missed. I would support urgent biopsy of the mass and an axillary node with biomarkers prioritised. I would report the event through the incident system the same day and keep all material unaltered. I would ask for a root cause analysis covering correlation, workload and MDT review of benign results from suspicious lesions. I would propose compulsory discordance review and a look-back of my benign breast cores from the same period.

Ethics and communication: She has a right to know that an earlier result was wrong and may have delayed her diagnosis, and disclosure should be early, honest and led by the treating team with my participation. I would apologise without speculating on blame before the review. The case may be examined under Federal Decree-Law No. 4 of 2016 on Medical Liability, so I would cooperate and inform my indemnity provider. Quietly re-reporting or editing the original would be dishonest.

Reference: WHO Classification of Tumours: Breast Tumours (5th ed, 2019); ADASP Recommendations for Quality Assurance and Improvement in Surgical and Autopsy Pathology (2006); Federal Decree-Law No. 4 of 2016 on Medical Liability (UAE)

Knowledge: I would classify the tumour with the fewest stains, usually TTF-1 and p40, because a large panel exhausts tissue needed for molecular testing. The CAP, IASLC and AMP guideline requires at least EGFR, ALK and ROS1 testing in advanced adenocarcinoma, and current practice adds BRAF, KRAS, MET exon 14, RET, NTRK and HER2, ideally by a DNA and RNA panel. PD-L1 by a validated assay with tumour proportion score guides immunotherapy. ALK and ROS1 immunohistochemistry are valid screening tools using one section each. Plasma ctDNA can find drivers when tissue fails, but a negative plasma result does not exclude one.

Management: I would mark the best tumour area, order only TTF-1 and p40, and cut spare unstained sections in the same session to avoid re-facing the block. If adenocarcinoma is favoured, I would add PD-L1 and ALK and ROS1 immunohistochemistry per protocol. I would send the remaining sections for sequencing with macrodissection and a recorded tumour percentage. I would advise the oncologist to send plasma ctDNA in parallel to shorten time to an actionable result. I would issue an integrated report stating tumour content, assay limits and any failure. If sequencing fails, I would discuss re-biopsy at the thoracic MDT rather than issue an uninterpretable negative. I would not spend the last tissue on non-essential stains.

Ethics and communication: Tissue is finite and belongs to the patient's care, so I would explain to the oncologist why I will not run every stain requested. Some panels detect possible germline variants, and the report should flag these so the patient can be counselled and consent to germline testing. If material goes to a reference laboratory abroad, patient data must be handled in line with Federal Law No. 2 of 2019 and facility policy.

Reference: CAP/IASLC/AMP Updated Molecular Testing Guideline for Lung Cancer (2018); WHO Classification of Tumours: Thoracic Tumours (5th ed, 2021)

Knowledge: The features strongly favour Burkitt lymphoma, with diffuse large B-cell lymphoma and high-grade B-cell lymphoma with MYC and BCL2 rearrangements as the main differentials. Confirmation needs FISH for MYC rearrangement, with BCL2 and BCL6 probes to exclude a double-hit lymphoma. TdT must be negative to exclude lymphoblastic lymphoma, which can also look starry-sky. The WHO and International Consensus classifications separate these entities, and the distinction changes chemotherapy intensity. The raised urate and creatinine indicate spontaneous tumour lysis, which is the immediate threat and should not wait for FISH.

Management: I would prioritise the case, add TdT, MYC and EBER, and send unstained sections for urgent FISH. I would phone the haematologist that afternoon with an interim report: a highly aggressive B-cell lymphoma, most likely Burkitt, confirmation pending. This lets the team manage tumour lysis with hydration, rasburicase and nephrology input. I would issue a written report the same day labelled provisional and listing pending tests. I would note that HIV-associated Burkitt lymphoma is common and suggest testing through the treating team. If we lack lymphoma expertise, I would arrange a tracked second opinion. When FISH returns, I would issue an integrated final report and present it at the lymphoma MDT.

Ethics and communication: Urgency must not lower standards, so the interim result is labelled provisional verbally and in writing, with who I told and when. The patient should hear the diagnosis from his haematologist, so I would agree the timing of portal release with the team. HIV testing needs his informed consent, and a positive result is confidential and notified under Federal Law No. 14 of 2014.

Reference: WHO Classification of Haematolymphoid Tumours (5th ed); International Consensus Classification of Mature Lymphoid Neoplasms (2022)

Knowledge: This is a pT1 colorectal adenocarcinoma, and the questions are residual tumour at the polypectomy site and lymph node metastasis. High-risk histological features are poor differentiation, lymphovascular invasion, high-grade budding and a close or involved margin, with clearance of 1 mm or less widely treated as high risk. Depth is described by Haggitt level for pedunculated polyps and Kikuchi level or measured depth for sessile ones. Lymphovascular invasion should be confirmed on levels or with D2-40, because retraction artefact is common. Mismatch repair immunohistochemistry is recommended on all colorectal cancers to screen for Lynch syndrome.

Management: I would check the inked stalk and orientation, cut levels through the invasive front and margin, and order D2-40 and mismatch repair stains. I would ask a second gastrointestinal pathologist to review margin and budding, because these features drive major surgery. I would issue a structured report giving each risk factor in millimetres and grades, never the vague phrase completely excised. I would tell the gastroenterologist that several high-risk features are present and resection is likely to be discussed. At the MDT I would show the slides and explain measurement uncertainty, so the risk of surgery can be weighed against the risk of residual disease. If mismatch repair loss is found, I would advise MLH1 methylation or BRAF testing and genetics referral.

Ethics and communication: The decision for surgery belongs to the patient, guided by the MDT, and my report must state risk honestly. Possible Lynch syndrome affects relatives, so germline testing needs his consent and counselling, and he decides how results are shared with family. Clear documentation of measurements protects the patient and the clinicians if outcomes are questioned.

Reference: WHO Classification of Tumours: Digestive System Tumours (5th ed, 2019); ICCR Colorectal Excisional Biopsy (Polypectomy) Histopathology Reporting Guide

Knowledge: Massive pulmonary embolism is most likely, with myocardial infarction, arrhythmia, occult haemorrhage and aortic dissection in the differential. A hospital autopsy needs next-of-kin consent and is limited to what they agree. A sudden unexpected death after surgery with a possible omission in care should be reported to the competent authorities in line with UAE law and facility policy. If they take jurisdiction, any examination is medicolegal, and I should not perform a consented autopsy in its place. Less invasive options, such as post-mortem CT angiography or needle sampling, are often acceptable to families.

Management: I would ask the treating consultant to make sure the timeline and the absence of prophylaxis are documented accurately and left unaltered. I would advise prompt reporting through the hospital route for unexpected deaths and would not start an autopsy while that decision is pending. I would ask that lines and tubes stay in place and that pre-death blood samples be retained. If the authorities decline jurisdiction, I would meet the family with the treating doctor and a religious liaison, explain what an autopsy can answer and offer a limited examination, imaging or no autopsy. I would agree a timetable that respects early burial as far as possible. I would also ask that the missed prophylaxis be reported as a serious incident.

Ethics and communication: The family's beliefs deserve respect, but the duty to report a possibly care-related death cannot be traded for a quick burial. I must not promise an outcome I do not control. Any consent must be informed, specific and recorded with its limits. The missed thromboprophylaxis should be disclosed to the family by the treating team, because concealing it would be dishonest.

Reference: Burton and Rutty, The Hospital Autopsy: A Manual of Fundamental Autopsy Practice (3rd ed, 2010); Saukko and Knight, Knight's Forensic Pathology (4th ed, 2016)