Elizabeth Montgomery, MD
@LizMontgomeryMD
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Gastrointestinal & soft tissue pathologist. Professor of Pathology at University of Miami. Founder of @science_press
Miami FL
Joined July 2018
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From - Parra-Herran C, Khani F, Wobker SE. Gender distribution of editors and authors of reference textbooks in anatomic pathology. Mod Pathol. 2022 Sep 7. Epub ahead of print. PMID: 36071098.
It’s nice that we have gender parity amongst our authors at Innovative Science Press.
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...sneaky sneaky. Kaposi sarcoma in gastric mucosa.
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A beautful day for colorectal malakoplakia. Note the nice Michaelis-Gutmann body (arrow). It is a 4x diagnosis because of the characteristic brightly eosinophilic appearance of the histiocytes. Once one spots the first MG body, more follow ...but fun to confirm with Von Kossa.
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Bread and butter: if you see such lush neuroendocrine granules in a NET involving the liver, you can be quite certain that the primary is ileal.
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This is a lovely example of "sneaky" strongyloidiasis. I cannot take credit for spotting the organisms - my new colleague Dr. Jonathan England was the hawk-eye!
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Good gosh - I initially mistook this for a rare gastric carcinoma with peculiar oxyntic/parietal cell differentiation. Gulp. Thankfully I realized my error in a reasonable time frame.
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My colleague Dr. Alan George here at the University of Miami (my new home since 07/2020) managed to take this impressive picture of gastric H. heilmannii with his mobile phone. This is an immunohistochemical stain for H. pylori, which cross-reacts.
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Pembrolizumab-associated colopathy/colitis. There is lots of immune damage to the colonic mucosa. The crypt apoptosis is striking. This is the other side of the miracle of immunotherapy.
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Incredible example of a TFE3-rearranged PEComa that presented as a colorectal polyp.
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Just a divine colonic lipoma that everyone needed to enjoy.
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Ugh. Melanoma fooled me. Two initial immunostains (desmin and actin) were negative - I regrouped and sorted it out. Not the first time - won't be the last. Melanoma's always there to humble us.
#UMiamiPath
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Morphology remains critical in the genomic era; Two lesions of the gastric muscularis propria with MALAT1-GLI1 fusions; one (gastroblastoma) is malignant and the other (plexiform fibromyxoma) benign.
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Schistosomiasis presenting as a rectal polyp - the ova have mineralized. It's probably S. hematobium.
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This was a "good gosh!" case. A "routine" appendectomy with mesothelioma. Gulp!
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Entities that are 100% H&E diagnoses are the best! Pleomorphic liposarcomas feature some of the most bizarre cells in human neoplasia. This example has beautiful pleomorphic lipoblasts, all decked out with lipid droplets crisply indenting their nuclei.
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Super scary. At low magnification, this little focus looked like "squamous morules" to me... boring, next case..... but the cells are ugly and mitotically active. A tiny neuroendocrine carcinoma arising in the setting of a tubular adenoma. Gulp.
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This dramatic example of metastatic melanoma to the stomach shows striking pigmentation.
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Starting to clean out my Johns Hopkins office in preparation for moving to Miami on 1 July 2020. Found this example of cytomegalovirus pneumonitis from the AIDS era. Thanks to research, HIV-infected people can now live decent lives with complete suppression of their viral loads.
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A striking case of histoplasmosis. It really is nasty about mimicking Crohn's disease.
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This colonic lipoma is very proud of itself. It is taking a bow for an excellent performance.
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This is simply an amazing example of lymphatic space invasion "caught in the act" in what appears to be intramucosal (muscularis mucosae invasion) carcinoma in a colorectal polypectomy sample. Of course there might be submucosal invasion that simply is not apparent on the slide.
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Many things in life are about perspective. This little delight is either a heart or a butt.
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This is a nice example of a gastric pyloric gland adenoma with high grade dysplasia. The patient had autoimmune gastritis.
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Gastric glomus tumor - don't be fooled by the synaptophysin. They are negative for chromogranin and keratins.
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Low grade endometrial stromal sarcoma presenting as a colon polyp. That lobulated appearance is a clue.
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This image of colonic strongyloidiasis is courtesy of Dr. Dale Snover, who has retired from the University of Minnesota.
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Gallbladder high grade dysplasia extending into Rokitansky-Aschoff sinuses (oh, right, biliary intra-epithelial neoplasia, high grade, BilIN)
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Human papilloma virus (HPV)-associated anal neuroendocrine carcinoma, small cell type. Note the dot-like synaptophysin expression and the in situ hybridization for high risk HPV.
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A nice example of iron pill gastritis. That golden brown color is perfect for autumn.
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Stunning example of a clear cell sarcoma-like tumor of the ileum (also termed gastrointestinal neuroectodermal tumor). These tumors express S100 protein but not "melanoma markers" (as opposed to classic clear cell sarcomas, which express "melanoma markers").
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Duodenal follicular lymphomas are often so indolent that the WHO gave them their own separate category and they are generally managed by observation alone. The neoplastic follicular cells retain their characteristic BCL6 expression but the cells aberrantly express BCL2.
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I guess the party's over. Cocaine-associated ischemic colitis.
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This is the type of colon biopsy that separates the men and women from the boys and girls. The sessile serrated adenoma is obvious; the adults spot the systemic mastocytosis in the flat mucosa.
#UMiamiPath
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What a stunning syphilis gastritis case courtesy of my colleague Lysandra Voltaggio here at Johns Hopkins. It looks so much like the severe destructive gastropathy of autoimmune pangastritis but the treponemal immunostain sets us straight!
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This colonic tubular adenoma managed to catch cytomegalovirus.
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Syphilis gastritis from the daily work. It creates a destructive gastropathy that has overlapping features with EBV gastropathy and some drug-associated gastropathies.
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Critters from the week - cytomegalovirus colitis and giardiasis in small intestine.
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This micropapillary urothelial carcinoma spread to the duodenum. Nasty nasty tumor.
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With all this quarantine drinking going on, we all need to remember what alcohol can do to our livers. Cirrhosis is rough, but the Mallory-Denk bodies (some with arrows) in this case are classic.
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Perfect Mallory bodies are just about right for a Friday afternoon.
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Syphilis pharyngitis in Miami. We are more than just the booty shakin' capital.
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Neuroendocrine tumor (NET) grade 3 using Ki-67; in the past neuroendocrine carcinoma/NEC based on the proliferation index. Therapy differs for G3 NET (somatostatin analogues, mTOR inhibitors, alkylating agents, VEGF inhibitors) versus NEC (platinum based).
#UMiamiPath
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A beautiful example of Whipple disease from the catch. A former colleague, Dr Christina Arnold, wrote a lovely summary of this lesion some time ago.
#UMiamiPath
Am J Surg Pathol. 2012 Jul;36(7):1066-73. PMID: 22743287.
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A perfect example of celiac disease. Of course the diagnosis is not made on histology alone; the patient had appropriate serologic findings.
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Eosinophil-rich apoptotic enteropathy with crypt loss in a patient with debilitating diarrhea - chart dig: the patient was taking losartan, one of the angiotensin receptor blocker "sartans" associated with this issue. Guess the patient will try a new anti-hypertensive!
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The lowly PAS stain is much more useful than the Ki-67 in confirming that the severe changes in this gastric antral biopsy are reactive - the mucin surface is nicely intact!
Reference: PMID: 32841414; PMCID: PMC9281539.
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Vascular transformation of sinuses of lymph node (nodal angiomatosis) is just an incidental finding in nodes to make us nervous....
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Cytomegalovirus (CMV) gastritis and colitis. Arrows show the stromal colonic viral cytopathic effect. Two arrows show an infected gastric endothelial cell and one shows an infected epithelial cell. The top arrow in the gastric biopsy shows apoptosis, often associated with CMV.
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Scleroderma is so easy to diagnose when we remember to consider it! The trichrome stain really highlights the sclerosis (progressive systemic sclerosis).
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Another pleomorphic liposarcoma for interest.
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A spectacular mycobacterial spindle cell tumor. The foamy cells popped up on the special stains! The patient has HIV/AIDS.
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This solid alveolar rhabdomyosarcoma has beautiful rhabdomyoblasts, strong myogenin staining, and is stuffed with glycogen.
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This wonderful case is courtesy of Scott Saul . The appendix was resected from a 28 year old with right lower quadrant pain- appendiceal PEComatosis! Acute appendicitis was also present. Only 4 cases of this type in literature. Please enjoy this!
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Pancreatic IgG4 related fibrosclerosing disease (autoimmune pancreatitis) is easiest to diagnose on needle biopsies with the help of an elastic stain, which pops out the inconspicuous obliterative phlebitis. See more images on Facebook.
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This is a pretty colonic granular cell tumor. They tend to have nuclear enlargement but a good outcome.
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First pyloric gland adenoma at the U of Miami. Woo woo!
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What a treat - enterobius vermicularis in an appendectomy. Pinworms! Note the lateral alae and enough eggs for an omelet. Delish!
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Pancreatic mucinous cystic neoplasm, featuring ovarian-like stroma and mucinous epithelium with, in this case, both low and high grade dysplasia.
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Striking angiosarcoma, probably post-radiation. The immunostain is CD31.
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The WHO has recently decided that sessile serrated adenoma should be termed sessile serrated LESION. I personally think this is idiotic because these things behave like adenomas and SSA is the term coined by Dale Snover Dale found the baby, let him name his baby…
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A tiny sneaky gastric poorly cohesive/signet ring cell carcinoma in uninflamed gastric oxyntic mucosa. Makes one wonder about hereditary diffuse gastric carcinoma...
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Stunning example of the cholangioblastic variant of intrahepatic cholangiocarcinoma. At first glance these look like neuroendocrine tumors and there is chromogranin/synaptophysin expression (patchy) but not INSM1. The kicker is inhibin. PMID: 33999553; PMCID: PMC8516671.
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Well differentiated neuroendocrine (carcinoid) tumor, Type 3, arising in normal oxyntic mucosa is more aggressive than type 1 (associated with autoimmune gastritis). A pitfall on mucosal biopsies is that mucosa over the lesion can appear atrophic.
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This is a lovely fat-rich solitary fibrous tumor (the old lipomatous hemangiopericytoma). Such perfect vessels!
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Traditional serrated adenoma (TSA) and tubular adenoma (TA) in the same biopsy cup. The nuclei in the TSA are much smaller and paler than those in the TA, even in the proliferation zones (the ectopic crypt formations).
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Crazy amazing case - meningioma in the liver. Once you think of it (and your KIT and DOG are negative....) it is so obvious!
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Enterohemorrhagic E. coli.. lots of fibrin thrombi and ischemic type injury.
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This pattern of duodenal injury suggests autoimmune enteropathy. Goblet cells and Paneth cells are missing and there is lots of crypt apoptosis.
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Dermatofibrosarcoma protruberans (DFSP) arising in a young person in a pre-existing giant cell fibroblastoma. The best part - the DFSP portion has melanin pigment (Bednar tumor component). Need a cigarette after such a dessert. Oops- I don't smoke.
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Sessile serrated adenoma (SSA) with high grade dysplasia. Alternatively, in the WHO terminology: sessile serrated lesion with dysplasia. Since we cannot grade dysplasia perfectly in SSA, we should not even try. Somehow we surmount our shortcomings elsewhere in the GI tract.
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Look at all the medications in this tiny portion of a gastric biopsy. The drugs present tell us that the patient has renal disease. Of course, microcrystalline cellulose is just pill filler. Kayexalate reduces hyperkalemia and Renvela reduces hyperphosphatemia.
#UMiamiPath
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From the recent catch. Metastatic pancreatic solid pseudopapillary tumor to the liver. The hyaline globules in this example are especially impressive.
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Gastrointestinal neuroectodermal tumor (clear cell sarcoma-like tumor) usually arises in the ileum of young adults, can have a pseudopapillary appearance, and expresses S100 protein (shown).
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A sessile serrated adenoma (chose not say "lesion" as per WHO) with dysplasia. Looks HGD to me despite the suggestion of the WHO not to grade it because of poor inter-observer reproducibility even though everything else gets graded (despite suboptimal reproducibility).
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A nice cytomegalovirus (CMV) gastritis. It's interesting that it often infects gastric epithelium rather than endothelium.
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A perfect Reed-Sternberg-like fibroblastic cell in a myxoinflammatory fibroblastic sarcoma. There is a new series of these in Mod Pathol. Suster D is the first au
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Some people never get tired of pyloric gland adenomas, especially when they arise in patients with familial adenomatous polyposis and have areas of high grade dysplasia.
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Sessile serrated adenoma - the lining is so fluffy that the crypt at the left looks like an Uggs boot.
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A very very sneaky example of Kaposi sarcoma involving the liver. Ouch.
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Chromophobe renal cell carcinoma has spread to the colon. Many immunohistochemical stains would have been wasted without history!
#UMiamiPath
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The stomach is the most common site for gastrointestinal tract synovial sarcoma. Note the monotonous cytologic features. Nowadays, it can be a "one stain diagnosis".
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The latest creature feature here in Miami! Strongyloidiasis.
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A sessile serrated adenoma with dysplasia. Looks like some HGD to me but the nice men at the WHO said that we shouldn't grade the dysplasia in these because we are not very reproducible. Of course we are 100% reproducible in other GI tract sites.
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This sigmoid colon tubular adenoma has the best pseudoinvasion.
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Every day is a good day for a solitary fibrous tumor. This one has all the nice features - the correct vascular pattern, a dusting of wiry collagen, and nuclei strewn every which way.
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Another sessile serrated adenoma with dysplasia - caught in the act..... of hopping on the fast track to cancer.
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Malignant peripheral nerve sheath tumor (MPNST) often has nuclei with one pointed and one flat end (bullet-shaped; arrows). This one also has loss of H3K27me3.
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Not much - a cute lamina propria perineurial proliferation associated with a sessile serrated adenoma.
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Cutaneous myofibromas are just plain cute with their biphasic pattern!
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This is a nice example of hepatocellular carcinoma in a cirrhotic liver that shows the pattern of endothelial cells wrapped around tumor cell groups and the beautiful reticulin distribution in the tumor and the adjoining cirrhotic liver.
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A subtle pancreatobiliary type adenocarcinoma that spread to the colon. In this case, loss of SMAD4/DPC4 was useful in confirming the interpretation.
#UMiamiPath
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Puetz-Jeghers polyps love to undergo intussusception and this can result in herniation of glands (pseudoinvasion/enteritis cystica profunda pattern), sometimes all the way through to the serosa. This can be a fooler for adenocarcinoma. Beware!
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Classic necrobiotic granulomas in rheumatoid nodule. The patient had a long history of rheumatoid arthritis and bilateral nodules on his fingers.
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Salivary gland heterotopia of the rectum. Is this like having one's head _______?
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Colorectal systemic mastocytosis. Note the pale lamina propria and the oval nuclei and eosinophils.
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