1. Interesting Case Presentation Written by: Neil Blackwell This case was provided by: GynaePath – Douglass Hanly Moir Pathology, Sydney, Australia.

2. Patient History 37-year-old female Reporting abdominal discomfort and bloating LMP 2 weeks ago Normal appearing cervix Conventional Pap smear and ThinPrep ® Pap Test collected 2

3. Conventional Slide 3 Blood and inflammation 10x

4. ThinPrep ® Pap Test 4 Hyperchromatic crowded groups 10x

5. 5 ThinPrep ® Pap Test 3-Dimensional groups 40x

6. ThinPrep ® Pap Test 6 Eccentrically placed nuclei 40x

7. ThinPrep ® Pap Test 7 Papillary-like projections 40x

8. ThinPrep ® Pap Test 8 Finely granular cytoplasm 40x

9. ThinPrep ® Pap Test 9 Cytoplasmic vacuolization 40x

10. ThinPrep ® Pap Test 10 Granular chromatin 40x

11. ThinPrep ® Pap Test 11 Variation in nuclear shape & size 40x

12. ThinPrep Pap Test 12 Background clingy diathesis 40x

13. ThinPrep ® Pap Test 13 Prominent nucleoli and scalloped edges 40x

14. Ancillary testing from the Vial 14 Residual material: Agar cell bock from ThinPrep vial H&E section 14 Immunocytochemistry Panel

15. Cell Block from the ThinPrep ® Vial 15

16. Immunocytochemistry CA-125 16 Membranous staining

17. Final Cytology Diagnosis Adenocarcinoma Strong membranous staining of the tumour cells are suggestive of a tumour –Ovarian (most likely) –Biliary duct and breast (can not be excluded) –Clinical and Radiological correlation is recommended Cell block and Immunohistochemical stains Positive: CA125 CK7, CK19 Negative: PAX8, CK20, p53, p16, ER & PR, AMACR, NAPSIN A, HNF 1B, CDX 2,GATA3, P63 The cell block shows multiple groups and clusters of malignant cells with high nuclear to cytoplasmic ratio, pleomorphic nuclei and prominent nucleoli The features are consistent with an adenocarcinoma 17

18. Patient follow up 18 Investigative tests were ordered for lower pelvic discomfort, abdominal distention and Sister Mary Joseph’s nodule: Pelvis U/S - Showed an ascites CT Scan Referral to a Gynaecologist Treatment: Radical hysterectomy - Stage IV High Grade Ovarian Ca Rectosigmoid resection Peritonectomy Chemotherapy 1. http://bjgp.org/content/63/615/551 Example of Sister Mary Joseph’s nodule 1 ADS-01458 Rev. 001