Recurrent invasive ductal carcinoma of the breast with metastasis to the uterine cervix: A case report

This article presents a case of cervical metastasis from recurrence of invasive ductal carcinoma of the breast >20 years after initial diagnosis. The diagnosis was made after the patient presented with three months of intermittent post-menopausal vaginal spotting. She underwent palliative radiotherapy combined with chemotherapy and was disease free at the time of writing. Cervical metastasis of a primary breast cancer is extremely rare and can present with a variety of symptoms. This case report highlights the importance of life-long gynecologic care and surveillance in patients with a history of breast cancer.

Interactive Pathology Tutorial in Neoplastic Hematology Disorders for Medical Hematology-Oncology Fellows

Hematology-oncology (HO) fellows receive limited instruction in the process of establishing a diagnosis for hematologic neoplasms, and learning neoplastic hematology often occurs in limited encounters. In the current study, we developed a web-based interactive pathology tutorial in neoplastic hematologic disorders for HO fellows to work up simulated cases and establish the diagnosis. An online system ("Pathology Playground") was utilized to load case materials including microscopic images and ancillary studies. Twelve high-yield simulated cases of common leukemias and lymphoma were included. At the beginning of each case, trainees review the clinical history and slide images, and then, they are given the option to request additional pathology work-up. Based on the results, they can enter their diagnostic impression. If the diagnosis is correct, the user is shown a short educational presentation. If the diagnosis is not correct, the user gets notified by the message "Incorrect." The tutorial was integrated in the educational curriculum of our HO fellowship program, and bimonthly teaching sessions were held to review two cases each time. During the sessions, trainees request ancillary studies to complete the diagnostic work-up using the software and interpret the findings. As the case is being worked up by the trainee, the hematopathologists and HO fellowship program director discuss the findings, the appropriate work-up tools, and the implications on management. All of our six HO fellows attended the sessions, and a survey from the trainees showed high ease of use of the system and they viewed it as a very useful educational tool. A pre-test and post-test were administered for one of the sessions, and the result showed improvement in the average from 62 to 73%. Expanding the use of this online interactive tutorial and incorporating additional cases would enhance its value as a learning resource.

Small Bowel Neuroendocrine Neoplasms-A Review

ABSTRACT

Neuroendocrine neoplasms (NENs) are rapidly evolving small bowel tumors, and the patients are asymptomatic at the initial stages. Metastases are commonly observed at the time of presentation and diagnosis. This review addresses the small bowel NEN (SB-NEN) and its molecular, histological, and imaging features, which aid diagnosis and therapy guidance. Somatic cell number alterations and epigenetic mutations are studied to be responsible for sporadic and familial SB-NEN. The review also describes the grading of SB-NEN in addition to rare histological findings such as mixed neuroendocrine-non-NENs. Anatomic and nuclear imaging with conventional computed tomography, magnetic resonance imaging, computed tomographic enterography, and positron emission tomography are adopted in clinical practice for diagnosing, staging, and follow-up of NEN. Along with the characteristic imaging features of SB-NEN, the therapeutic aspects of imaging, such as peptide receptor radionuclide therapy, are discussed in this review.

Diffuse Large B-cell Lymphoma of the Orbit With Intracranial Extension: A Rare Entity

Primary diffuse large B-cell lymphoma of the orbit is a rare diagnosis that accounts for less than 1% of all non-Hodgkin's lymphoma (NHL) cases. We present here the case of a middle-aged woman with a past medical history of intellectual delay and hypothyroidism who presented with a large diffusely infiltrating mass of the left orbit. A biopsy of the lesion during the patient's hospitalization confirmed a diagnosis of diffuse, large B-cell lymphoma. Due to extensive local invasion, she was deemed a poor surgical candidate. While inpatient, she was started on systemic chemotherapy and discharged with close follow-up planned with the oncologic and surgical teams.

Adamantinoma-like Ewing sarcoma of thyroid gland-An unfamiliar mimicker of epithelial and mesenchymal neoplasms of the head and neck

INTRODUCTION

Adamantinoma-like Ewing Sarcoma (ALES) is a rare variant of the Ewing family of tumours (EFT) harbouring the EWSR1-FLI1 translocation and with complex epithelial differentiation. Very few cases of ALES involving thyroid have been reported in literature.

CASE REPORT

We report a case of ALES involving the thyroid in a 61-year-old male who presented with an enlarging nodule in the left lobe of the thyroid and underwent hemithyroidectomy.

DISCUSSION

ALES demonstrates morphologic similarity to a multitude of epithelial and mesenchymal tumours, creating a potential diagnostic pitfall in thyroid and head and neck pathology. Given the rarity of this tumour, there is also a lack of accepted guidelines regarding further surgical management of these cases following hemithyroidectomy.

Pathology Playground: An Interactive Web-Based System for Pathology Unknowns With Immunohistochemistry and Molecular Studies

CONTEXT.—

Anatomic pathology slide unknown conferences are usually limited to a microscopic slide, slide images, or a virtual slide that is previewed prior to a conference. The answer is provided at a conference along with the ancillary studies, such as immunohistochemical or molecular studies, that enabled the diagnosis. In this rigid system the learner never gains experience with an appropriate workup for cases that will enable the definitive diagnosis.

OBJECTIVE.—

To develop an interactive system in which the user can work through a difficult case, ordering stains and other special studies, ideally leading to more involvement and retention.

DESIGN.—

An online system was developed using HTML, PHP Hypertext Preprocessor, and JavaScript for ordering and result display. When the user selects a study, an image or text result is displayed. Studies include immunohistochemistry, cytogenetics, flow cytometry, molecular, and radiology. The user then selects the diagnosis and, if correct, is shown some additional didactics.

RESULTS.—

Unknown conferences were held at 3 institutions using this novel teaching method that allowed residents to work up unknown cases. Conferences are available online (http://www.drdoubleb.com/unknowns/) and include general, soft tissue, and hematopathology cases. Evaluations were obtained that showed that residents enjoyed the system, considered it better than standard unknown sessions and lectures, and wanted more sessions.

CONCLUSIONS.—

This system was very highly received by the residents in all programs, who enjoyed getting immediate results and being able to work through interesting cases. More widespread use of this system could make for an effective learning tool.

The prognostic significance of duodenal wall invasion in pancreatic adenocarcinoma

OBJECTIVE

The most recent edition of the American Joint Committee on Cancer Staging Manual (AJCC, 8th edition) relies only on tumor size for staging resectable pancreatic adenocarcinoma, and the presence of duodenal wall invasion (DWI) no longer has an impact on staging. However, very few studies have evaluated its significance. In this study, we aim to evaluate the prognostic significance of DWI in pancreatic adenocarcinoma.

METHODS

We reviewed 97 consecutive internal cases of resected pancreatic head ductal adenocarcinoma, and clinicopathologic parameters were recorded. All cases were staged according to the 8th edition of AJCC, and the patients were divided into two groups based on the presence or absence of DWI.

RESULTS

Out of our 97 cases, 53 patients had DWI (55%). In univariate analysis, DWI was significantly associated with lymphovascular invasion and lymph node metastasis (AJCC 8th edition pN stage). In univariate analysis of overall survival, age > 60, absence of DWI, and African American race were associated with worse overall survival. In multivariate analysis, age > 60, absence of DWI, and African American race were associated with worse progression-free survival and overall survival.

CONCLUSION

Although DWI is associated with lymph node metastasis, it is not associated with inferior disease-free/overall survival.

Primary Effusion Lymphoma Presenting As Parapneumonic Pleural Effusion

Primary effusion lymphoma (PEL) is a rare form of high-grade non-Hodgkin's lymphoma that usually occurs in patients with compromised immunity or human immunodeficiency virus (HIV) infection. PEL is a B-cell lymphoma that principally presents as effusions without a tumor mass. We present a case of a 56-year-old African-American male with a medical history of HIV admitted to the hospital with right lung lower lobe pneumonia and parapneumonic effusion. Thoracentesis and pleural fluid cytology led to the diagnosis of PEL. He received treatment with chemotherapy and antiretroviral therapy (ART). The emphasis is to investigate immunocompromised patients presenting with pleural effusion for PEL, as it is a rare ailment with a high mortality rate.

Flow Cytometric Findings in Primary Effusion Lymphoma: A Report of Two Cases

Primary effusion lymphoma (PEL) is a rare B-cell lymphoma that usually occurs in the setting of HIV infection, and it is associated with Human Herpesvirus-8 (HHV-8). Diagnosis of PEL is usually established in cell centrifuge, cell block, or tissue examination, and there are few reports describing flow cytometry findings in PEL. We report two male patients (a 34-year-old and a 56-year-old) with a history of HIV infection. The first patient presented with ascites and abdominal pain, and the second patient presented with chest pain and parapneumonic pleural effusion. Cavitary fluid examination showed large pleomorphic neoplastic lymphoid cells with plasmablastic morphology. Flow cytometry analysis of the neoplastic lymphocytes showed increased forward scatter and side scatter with intermediate to a high level of CD38 expression. In one patient, lymphoma cells showed bright CD45 expression with dim expression of CD19 and kappa light chain. There was no significant expression of CD20 or any T/NK cell markers in either case. Immunohistochemistry for CD30 was positive in one patient. Immunohistochemistry for HHV-8 and in situ hybridization for Epstein-Barr virus-encoded small RNAs (EBER) was positive on cell blocks in both cases, consistent with the diagnosis of primary effusion lymphoma. PEL should be considered in the differential diagnosis of CD20-negative hematopoietic neoplasms, and flow cytometry may provide helpful clues for the diagnosis of PEL as part of the workup for pleural effusion with cytologically malignant cells.

Concomitant Gastric Malignancy and Hepatocellular Carcinoma

Multiple primary malignant tumors (MPMTs) are two or more separate malignancies found at different sites concurrently. Prior studies have shown that the most common tumor associations in MPMTs are typically between two tumors in the digestive system. We present a case of a male patient in his 60s who initially presented with melena and was found to have a clean-based gastric ulcer on initial endoscopic evaluation. Repeat endoscopy on later admission revealed persistent ulceration. Biopsy showed Epstein-Barr virus (EBV) positive lymphoepithelioma-like gastric carcinoma (LELGC), a rare gastric malignancy. The patient underwent endoscopic ultrasound (EUS) for assessment of tumor depth and involvement of perigastric lymph nodes, but was incidentally found to have a liver lesion. Biopsy of the liver lesion was positive for hepatocellular carcinoma (HCC) with no morphologic similarity to the gastric malignancy. This case highlights a rare finding of MPMTs. In addition to the diagnosis of a rare gastric malignancy, the patient developed a well-known but uncommon phenomenon of non-cirrhotic HCC associated with hepatitis C virus (HCV). Due to an increasing number of advances in cancer therapy that are leading to increased survival times, clinicians can expect for a patient to develop MPMTs in their lifetime. A high index of suspicion must exist for the possibility of MPMTs because treatment options and outcomes can be vastly affected by their findings.

HPV Associated Squamous Cell Carcinoma in the Rectal Tonsil

Mucosa-associated lymphoid tissue has been reported throughout the gastrointestinal tract including rectum. Rarely, a nodular proliferation of predominantly submucosal lymphoid tissue in the rectum has been documented as rectal tonsil. Here we report a patient with HPV-associated squamous cell carcinoma of the rectal tonsil, presenting as a polyp. Previously, rare reports of HPV-associated lymphoepithelial carcinoma have been reported in the literature. We are presenting an extremely rare occurrence and emphasizing the importance of appropriate nomenclature based on the pathogenesis of the neoplasm.

Gamma-Delta Large Granular Lymphocytic Leukemia: A Diagnostic Dilemma

We report an initial diagnostic dilemma case of a 60-year-old male who presented with worsening hemolytic anemia, thrombocytopenia, and acute kidney injury requiring hemodialysis. His presentation was initially suspected to be secondary to thrombotic thrombocytopenic purpura (TTP) and he was treated with intravenous immunoglobulin (IVIG) and plasmapheresis. Despite treatment, he failed to improve during his admission leading to further workup revealing gamma-delta T-cell large granular lymphocytic (γδ T-LGL) leukemia. In this paper, we will discuss the features, workup, and treatment of this rare malignancy.

Clavicular Metastasis as an Initial Presentation of Papillary Thyroid Cancer

OBJECTIVE

We present the case of a 44-year-old man with a large neck mass to highlight the unique presentation of papillary thyroid carcinoma (PTC) metastatic to the clavicle.

METHODS

We reviewed the medical record for a detailed history and physical examination findings. Our radiology colleagues examined the diagnostic imaging studies performed. The pathology team reviewed the neck mass biopsy and the confirmatory surgical pathology after total resection of the mass.

RESULTS

A 44-year-old man presented with an enlarging neck mass. Initial X-rays revealed a large soft tissue density mass that extended to the midline of the right clavicle. A neck ultrasound established a 5.4 × 3.6 cm mass with increased vascularity and calcification extending from the thyroid. A CT scan noted the extension of the mass into the adjacent sternoclavicular junction with osteolysis of the middle third of the clavicle and the superior aspect of the sternal body. Fine-needle aspiration revealed a thyroid neoplasm with follicular features and positive immunostaining consistent with thyroid carcinoma. The patient underwent a composite resection of the tumor, including a segmental osteotomy of approximately two-thirds of the medial clavicle. The pathology report confirmed PTC with extrathyroidal extension and clavicle involvement (staged pT4a pN0), with further genomic findings showing positive KRAS mutation.

CONCLUSION

Clavicular metastasis from differentiated thyroid cancer is rare. While the prognosis is generally favorable, various factors, including age greater than 45 years, poor differentiation, follicular thyroid carcinoma, Hurthle cell variant, and extrapulmonary metastasis, have typically been associated with poorer cancer-specific survival.

Clavicular Metastasis as an Initial Presentation of Papillary Thyroid Cancer

Background: Papillary thyroid cancer (PTC) metastases to the clavicular bone is rare. While the lung is considered the most common site of metastases from thyroid malignancy, osseous metastases, if seen, are usually observed at sites such as humerus, pelvis, radius, and scapula.

Clinical Case: A 44-year-old man presented with an enlarging right neck mass for six months after light trauma to that area. Other than mild pain in the described area, the patient reported 20 lbs of weight loss. Initial x-ray revealed a large soft tissue density mass that extended to the midline of the right proximal clavicle. Soft-tissue neck ultrasound noted a 5.4 x 3.6 cm mass extending from the thyroid with findings of increased vascularity and calcification. CT scan of the neck depicted the extension of the mass into the adjacent sternoclavicular junction with osteolysis of the middle third of the clavicle as well as the superior aspect of the sternal body. A fine needle aspiration of the mass revealed thyroid neoplasm with follicular features and positive immunostaining consistent with thyroid carcinoma. Chest CT showed invasion into the right proximal clavicle, tracheal deviation and extension into the mediastinum. The patient underwent a composite resection of the tumor, including a segmental osteotomy of approximately two-thirds of the medial clavicle. Post surgically the patient’s serum calcium was low at 7.9 mg/dL with a concurrently low PTH of 9 pg/mL and a low 25-hydroxyvitamin D of 16.8 ng/mL. Thyroglobulin was markedly high at 15655.0 ng/mL (confirmed on dilution), and thyroglobulin antibody < 1.0 IU/mL. Pathology report confirmed PTC with extra-thyroidal extension and involvement of clavicle (staged pT4a pN0), however margins and lymph nodes were negative for carcinoma with further genomic findings showing positive KRAS mutation. The patient’s post-operative course was complicated by a large expanding left neck hematoma after a fall; he was immediately readmitted with the hematoma subsequently safely evacuated. Levothyroxine has been held at this time with plans for radioactive iodine treatment eight weeks after surgery.

Conclusion: Bone metastases from differentiated thyroid cancer is rare, especially clavicular metastasis arising from PTC. Bone scintigraphy, x-ray and fine needle biopsy are some of the widely utilized methods employed in the evaluation of bone metastasis in the setting of thyroid malignancy. The prospect of recovery is generally favorable in cases of bone metastases, however various factors can affect prognosis and long-term outcomes.

Reference: Krishnamurthy A. Clavicle metastasis from carcinoma thyroid- an atypical skeletal event and a management dilemma. Indian J Surg Oncol. 2015;6(3):267-270. doi:10.1007/s13193-015-0387-y

Pitfalls in Morphologic Diagnosis of Pathogens: Lessons Learned From the Pseudo-Cystoisospora Epidemic

Multiple groups have recently reported involvement of the gallbladder mucosa of immunocompetent patients by cystoisospora organisms. However, this has recently been disproved with the support of molecular and ultrastructural studies. Here we present a summary of these events, recounting how this pseudo-Cystoisospora epidemic began and ended. This review also highlights the important role played by ancillary techniques in supplementing the morphologic diagnosis of pathogens.

Renal Cell Carcinoma with Right Ventricular Metastatic Spread: An Unusual Finding with Poor Prognosis

•RCC is the most common type of renal cancer. •RCC is capable of passing through the renal vein into the IVC. •Surgical resection requiring cardiopulmonary bypass is currently the only curative treatment. •Metastatic RCC tumor spread into the heart is a poor long-term prognostic factor.

Multiple myeloma with hepatic amyloid light-chain amyloidosis manifesting as progressive liver failure

We present a case of a 45-year-old man admitted to the hospital with new-onset ascites and bilateral subconjunctival haemorrhages. He was found to have elevated liver enzymes in a hepatocellular pattern and direct hyperbilirubinemia. A diagnostic paracentesis was consistent with portal hypertension (PH). Extensive workup for acute and chronic liver disease was unremarkable. In the absence of clinical evidence of cirrhosis to explain PH, a liver biopsy with hepatic venous pressure gradient was pursued, which revealed proteinaceous material and apple-green birefringence under polarised light consistent with amyloid deposits. Bone marrow biopsy revealed plasma cell neoplasm with proteinaceous deposits consistent with concomitant multiple myeloma with AL amyloidosis. He developed rapidly progressive liver failure and passed shortly after presentation despite treatment with chemotherapy. This case illustrates how primary hepatic amyloidosis can present with a physiology that mimics cirrhosis and can easily be missed.

Upper Abdominal Primary Retroperitoneal Cyst with Unusual Urothelial Histogenesis - An Uncommon Presentation Masquerading as a Hepatic Cyst

Background: Benign retroperitoneal cysts are uncommon. There is a paucity of literature on primary upper abdominal retroperitoneal cysts of urothelial histogenesis. We report an uncommon presentation of urothelial cyst clinically mimicking a hepatic cyst. Case presentation: A 21-year old female patient was admitted with intermittent abdominal pain of 9 months duration diagnosed on radiology as a right hepatic cyst. Laparoscopic resection and pathologic examination revealed a primary retroperitoneal cyst with a urothelial histogenesis. This is an unusual clinical presentation of a rare lesion mimicking a hepatic cyst. Conclusion: This case highlights the unusual anatomic location and the rare occurrence of an upper abdominal retroperitoneal urothelial cyst.

Ultrastructural Characteristics of Gallbladder Epithelial Inclusions Mimicking Cystoisospora

OBJECTIVES

There is recently reported increased prevalence of Isospora organisms in cholecystectomy specimens from immunocompetent patients, especially in acalculous cholecystectomies. We performed an ultrastructural and molecular evaluation of these specimens.

METHODS

From 28 gallbladders with intraepithelial inclusions, two specimens with diffuse involvement of the gallbladder epithelium were analyzed by electron microscopy. Polymerase chain reaction was performed on five samples for the ITS2 region of C belli and eukaryotic 18S region. The 18S products were sequenced by next-generation sequencing.

RESULTS

Electron microscopic analysis showed cytoplasmic condensations leading to vacuole formation. In contrast with true C belli, there were no identifiable organelles or organization. None of these cases showed amplified products other than human on molecular analysis.

CONCLUSIONS

Electron microscopic analysis demonstrates that the inclusions are condensed cytoplasmic material and not true organisms.

Prognostic significance of venous invasion in node-negative head and neck squamous cell carcinoma

BACKGROUND

Venous invasion (VI) is not frequently evaluated on routine histologic examination of head and neck squamous cell carcinoma (HNSCC), and the prognostic significance is largely unknown. Studies have shown that extramural venous invasion is an adverse prognostic factor in colorectal carcinoma. To our knowledge, this is the first study evaluating the prognostic significance of venous invasion in node-negative (without clinical or pathologic evidence of lymph node involvement) HNSCC, utilizing the elastic stain.

METHODS

A total of 105 consecutive lymph node-negative (N0) HNSCC were evaluated for the presence of venous channel invasion by tumor utilizing the elastin stain. Clinical, demographic, and follow-up data were recorded.

RESULTS

Of 37 patients with venous invasion, 19% had loco-regional recurrence, as opposed to 12% of those without. Univariate analysis revealed statistically significant decreased recurrence-free survival in the presence of venous invasion (log-rank [Mantel-Cox] test P-value .025).

CONCLUSION

Identification of VI is greatly aided by elastic stain. In patients with node-negative HNSCC, presence of VI resulted in decreased recurrence-free survival on univariate analysis. The impact of VI as a prognostic marker should be further evaluated.

Kaposi Sarcoma mimicking pedal osteomyelitis in a patient with HIV

Kaposi Sarcoma (KS) is an angio-proliferative mesenchymal neoplasm that typically affects the skin. In the setting of AIDS, it is usually disseminated, commonly involving noncutaneous sites like oral cavity, lymph nodes, pulmonary, and gastrointestinal systems. Musculoskeletal system involvement by KS is rare, and when encountered, it typically involves the axial skeleton (vertebrae, ribs, sternum, and pelvis) and/or maxillofacial bones. This report describes an unusual case of a 44-year old patient with HIV, who presented with a foot ulcer that fit the typical clinical features of osteomyelitis until MRI of the foot demonstrated atypical findings that challenged the original clinical diagnosis. This case highlights the role that advanced diagnostic imaging plays in the diagnosis of musculoskeletal Kaposi Sarcoma and serves as a reminder to radiologists to include Kaposi Sarcoma in the differential of multifocal osteolytic lesions in patients with HIV.

Safety and efficacy of over-the-scope clip-assisted full thickness resection of duodenal subepithelial tumors: A case report

BACKGROUND

Over-the-scope clip-assisted endoscopic full thickness resection (eFTR) of subepithelial tumors is a novel and promising endoscopic technique. Recently, there have been prospective studies investigating its use for colonic masses, but data regarding its use and efficacy in the duodenum are limited to a few reports.

CASE SUMMARY

A 65-year-old African American female presents for evaluation of persistent gastroesophageal reflux disease not responsive to medical treatment. A 1 cm nodule was incidentally found in the duodenum and biopsies revealed a low grade well differentiated neuroendocrine tumor. The nodule was removed using over-the-scope clip-assisted eFTR and pathology revealed clear margins. We review the available literature with a discussion on the efficacy and safety of clip-assisted eFTR s of subepithelial lesions in the duodenum.

CONCLUSION

Clip assisted eFTR appears to be a safe and efficacious treatment approach to duodenal subepithelial lesions. Further prospective studies are needed to investigate the long-term utility and safety of clip-assisted eFTR in the management of subepithelial duodenal lesions.

Pure Testicular Choriocarcinoma with Dermatological, Brain, and Gastrointestinal Metastases

Testicular choriocarcinoma is a non-seminomatous germ cell tumor (NSGCT) and is the rarest of all testicular cancers. Nearly all choriocarcinomas can be classified as either pure choriocarcinoma or as a component of a mixed germ cell tumor. Pure testicular choriocarcinoma is extremely aggressive and metastasizes early and extensively. We present a case of testicular cancer that metastasized to the skin, gastrointestinal tract, and brain, and discuss the case in light of the available literature.

Intestinal Schistosomiasis: A Rare Cause of Abdominal Pain and Weight loss

Abdominal pain is one of the most common reasons for outpatient visits. Although intestinal schistosomiasis is extremely rare in US, it should be considered in the differential diagnosis for those patients with risk factors such as international traveling history. This case report illustrates a unique case of intestinal schistosomiasis, which presented with an eight-week history of nonspecific abdominal pain and weight loss. Her colonoscopy revealed a 10 mm polyp in the colon. Endoscopic mucosal resection confirmed the diagnosis of schistosomiasis. Treatment with Praziquantel resulted in significant improvement of her symptoms.

Clinical, morphologic, and immunophenotypic characteristics of ampullary carcinomas with an emphasis on SMAD4 expression

BACKGROUND

The purpose of our study was to examine the relationship between clinicopathologic variables and morphologic subtypes in ampullary carcinoma, with an emphasis on the expression of SMAD4 tumor suppressor gene.

METHODS

Sixty-three cases of ampullary carcinomas resected between 2000-2011 were included in this study. Clinical characteristics and outcome data were recorded. Tumors were classified as pancreatobiliary or intestinal type based on morphology, and immunohistochemical (IHC) studies for cytokeratin 7 (CK7), cytokeratin 20 (CK20), cytokeratin 17 (CK17), and SMAD4 were performed.

RESULTS

Forty-nine percent of the ampullary tumors were pancreatobiliary, 29% were intestinal, and 22% were other variants. Tumors with pancreatobiliary morphology showed worse overall survival than those with intestinal morphology or other variants (P=0.03). A trend for higher stage, recurrence and less survival was seen in cases with negative SMAD4 expression. In multivariate analysis, age group (≤60 vs. >60 years) and expression of CK17 were the most prognostic of survival.

CONCLUSIONS

Ampullary tumors with pancreatobiliary morphology have a worse overall survival, while negative SMAD4 expression is associated with a trend of less survival.

EGFR family and cMet expression profiles and prognostic significance in esophagogastric adenocarcinoma

BACKGROUND

Targeted therapy with anti-human epidermal growth factor receptor-2 (HER2) monoclonal antibody in patients with HER2 overexpressed esophagogastric adenocarcinoma (EGA) improves survival; however, the effect is transient due to the development of resistance. Some studies suggest that cMet overexpression provides cross talk for epidermal growth factor receptor (EGFR) and HER2 inhibition. We sought to characterize the expression profile of the EGFR family and cMet receptors in untreated, resected EGA.

METHODS

This retrospective analysis included all sequential patients with esophageal or gastroesophageal junction (GEJ) adenocarcinoma who underwent primary resection, without neoadjuvant therapy or HER2 inhibition, with adequate tissue, at the University of Florida from 2001 to 2011. Central blinded immunohistochemistry (IHC) was performed on tumor specimens with EGFR, HER2, HER3, HER4 and cMet expression scored as low (0, 1+) or high (2+, 3+). Demographic and tumor characteristics were compared using Fisher exact test. Kaplan-Meier curves and univariate analysis compared survival among different receptors.

RESULTS

Total 52 patients were included in the study with median age 66 years. High expression of EGFR (73%), HER2 (40%), HER3 (75%), HER4 (35%) and cMet (69%) was detected among the study group. HER3 and HER4 co-expression was found in 18 (35%) cases. Pan expression of all four EGFR family members with cMet was noted in only 17% of cases. On univariate analysis, tumor stage and depth correlated with survival, while cMet + HER3 +/- EGFR receptor co-expression trended towards a worse survival.

CONCLUSIONS

EGFR family and cMet are frequently co-expressed in treatment naïve resected EGA or GEJ tumors. Although our data do not significantly show receptor status as a prognostic factor, the co-expression profiles support for further investigation to improve targeting of this signal transduction axis.

Discordant HER2 expression and response to neoadjuvant chemoradiotherapy in esophagogastric adenocarcinoma

BACKGROUND

Targeting human epidermal growth factor receptor 2 (HER2) with trastuzumab in metastatic esophagogastric adenocarcinoma (EGA) improves survival. The impact of HER2 inhibition in combination with chemoradiotherapy (CRT) in early stage EGA is under investigation. This study analyzed the pattern of HER2 overexpression in matched-pair tumor samples of patients who underwent neoadjuvant CRT followed by surgery.

METHODS

All patients with EGA who underwent standard neoadjuvant CRT followed by esophagectomy at the University of Florida were included. Demographics, risk factors, tumor features, and outcome data were analyzed. Descriptive statistics, Chi-square exact test, uni- and multivariate analyses, and Kaplan Meier method were used. HER2 expression determined by immunohistochemical (IHC) was scored as negative (0, 1+), indeterminate (2+) or positive (3+).

RESULTS

Among 49 sequential patients (41 M/8 F) with matched-pair tumor samples, 9/49 patients (18%) had pathologic complete response (pCR), 10/49 had near pCR or not enough tumor (NET) to examine in the post- treatment samples. Patients with initial HER2 negativity demonstrated conversion to HER2 positivity after neoadjuvant CRT (7/30 cases; 23%). Baseline HER2 overexpression was more common in lower stage/node negative patients (67% in stages I, IIA vs. 33% in stages IIB, III) and did not correlate with treatment response or survival.

CONCLUSIONS

Although limited by a relatively small sample size, our study failed to demonstrate that baseline HER2 protein over-expression in EGA predicts response to standard CRT. However, our data suggested that HER2 was up regulated by CRT resulting in unreliable concordance between pre-treatment (pre-tx) and post-treatment (post-tx) samples. Pre-therapy HER2 expression may not reliably reflect the HER2 status of persistent or recurrent disease.

Epithelioid Myofibroblastoma of the Breast: A Report of Two Cases with Discussion of Diagnostic Pitfalls

Mesenchymal lesions of the breast are uncommon lesions which present diagnostic dilemmas for even the most experienced pathologists. Here, we present two cases of the epithelioid-variant of myofibroblastoma which were misdiagnosed as malignant lesions. Careful integration of clinical presentation, imaging, and close examination of the gross, histologic, and immunohistochemical findings can assist in differentiating these challenging lesions and avoiding diagnostic pitfalls.

Interobserver variability of mitotic index and utility of PHH3 for risk stratification in gastrointestinal stromal tumors

OBJECTIVES

Accurate grading of gastrointestinal stromal tumors (GISTs), based on mitotic index, can be problematic.

METHODS

In this study, we compared interobserver variability in detecting mitosis on H&E with PHH3 immunohistochemistry (IHC). In addition, we examined the correlation between H&E mitosis and Ki-67 and the association of PHH3 and Ki-67 with overall survival. Four pathologists independently reviewed 50 GIST cases.

RESULTS

Intraclass correlation coefficients showed good interobserver variability for mitotic counts on both H&E (0.918; 95% confidence interval [CI], 0.874-0.950) and PHH3 IHC (0.923; 95% CI, 0.882-0.953). Nineteen (38%) cases were graded higher and five (10%) cases were downgraded by at least one observer using PHH3 compared with H&E. Using receiver operating characteristic curve analysis, a PHH3 cutoff of seven or more mitoses was associated with worse overall survival (P = .028). Ki-67 showed poor correlation with H&E mitotic counts and overall survival (P = .077).

CONCLUSIONS

PHH3 may thus be a valuable adjunct for risk stratification in GISTs.

Effect of neoadjuvant treatment with gemcitabine with nab-paclitaxel on SPARC and Ki-67 in patients with resectable pancreatic adenocarcinoma

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Background: Nab-paclitaxel (nab-P) and gemcitabine (Gem) improve survival in metastatic pancreatic cancer (PCa). We sought to determine the impact of nab-P and Gem on the primary tumor and associated microenvironment in neoadjuvant treatment (NAT). Methods: All patients in the GAIN-1 study (NCT01470417) received NAT with nab-P and Gem with or without radiation depending on risk status. A comparator group without NAT was matched for age, sex, race, resection status, smoking, primary tumor site, and tumor size. Surgical specimens of tumor, associated stroma and lymph nodes were analyzed. Routine immunohistochemistry (IHC) for Ki-67 and TUNEL was performed. Immunolabeling was assessed using anti-SPARC antibody (Invitrogen) with scoring consistent with prior reports: Negative = intensity absent to weak (+) with extent <10%; Positive = intensity moderate (++) to strong (+++) with extent ≥ 10%. For Ki-67 and TUNEL, the percentage of positive tumor cells was averaged over four HPF/specimen. Study was conducted with IRB approval. Results: A total of 30 unique patients were included in this analysis, 8 NAT cases and 22 matched controls. Clinical outcomes have been previously reported. Minimal to no SPARC expression was noted in either group of tumor cells. However, stromal SPARC expression was markedly reduced in NAT group (mean 2.88 ± 0.69%) compared to controls (28.43 ± 5.80%; p = 0.0002). Ki-67 was reduced in NAT group compared to controls (10.5 ± 2.83% vs. 36.76 ± 4.32%; p = 0.0004). TUNEL stain revealed a trend toward lower levels in NAT group (mean 1.13 ± 0.30% vs. 1.62 ± 0.31%; p = 0.574). SPARC, Ki-67 and TUNEL did not correlate with survival. Conclusions: SPARC expression in pCa primary tumors is low. Neoadjuvant nab-P and Gem significantly decreased stromal SPARC and tumor Ki-67. There was no change in TUNEL expression, indicating a population of residual viable cells. Additional stromal microenvironment change analysis in response to treatment is ongoing.

Expression relationships among EGFR family members and c-Met in esophagogastric adenocarcinoma

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Background: The incidence of esophagogastric adenocarcinoma is on the rise. The only targeted therapy that improves patient outcomes is the anti-HER2 antibody, trastuzumab; however, benefit is limited to cases with HER2 overexpression. Inhibition of EGFR in EGA is unsuccessful. cMet overexpression is a proposed resistance pathway for EGFR family inhibition. We sought to characterize the co-expression relationships among the EGFR family and cMet to identify potential dual therapeutic targets. Methods: This study included all sequential patients (pts) with adenocarcinoma of the esophagus and GEJ who underwent primary resection between 2001 to 2011 without neoadjuvant therapy or HER2 inhibition. Demographics, risk factors, tumor features, and outcome data were analyzed. Central blinded immunohistochemistry (IHC) was performed on FFPE tumor specimens with EGFR, HER2, HER3, HER4 and cMet expression scored as low/negative or high/positive expression. Descriptive statistics, Exact chi square test and Cox regression model were used for statistical analyses. Results: 48 pts (39 M/9 F) were eligible (median age 66yr; 37-83). Most (63%) were stage I (T1N0) and 93% had underlying Barrett’s esophagus. High expression of EGFR, HER2, HER3, HER4 and cMet were present in 70%, 43%, 77%, 38% and 56% of tumors respectively. HER3 and HER4 were commonly co-expressed (p=0.003) and moderately differentiated tumors had high expression of HER3 (p=0.01). Stage was the only variable that correlated significantly with survival (p=0.007). Conclusions: This study demonstrated that static baseline cMET expression levels are not associated with EGFR family expression profiles, although HER3/HER4 co-expression is common. No receptors demonstrated prognostic value. Further investigation into dynamic cMET expression changes related to active EGFR inhibition including prognostic and predictive value is warranted.

EGFR family and c-Met expression profiles and prognostic significance in esophagogastric adenocarcinoma

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Background: Targeted therapy of HER2 overexpression in patients with esophagogastric adenocarcinoma (EGA) improves survival; however, the effect is transient due to the development of resistance. Targeting of EGFR alone in EGA was not active. cMet overexpression is suggested to be a possible resistance pathway for EGFR and HER-2 inhibition. We characterized the expression profile of the EGFR family of receptors and cMet as well as their prognostic significance in EGA. Methods: This retrospective analysis included all patients (pts) with EGA who underwent primary resection at the University of Florida from 2001 to 2011 without neoadjuvant therapy. Demographics, risk factors, tumor features, and outcome data were analyzed. Central blinded immunohistochemistry (IHC) was performed on paraffin embedded tumor specimens with EGFR, HER2, HER3, HER4 and cMet expression scored as low (0, 1+) or high expression (2+, 3+). Descriptive statistics, Fisher exact test, Cox regression and Kaplan-Meier methods were used for statistical analyses. Results: 52 pts (42 M/10 F) were analyzed with median age 66 years (37-83). Most tumors (58%) were stage I (T1N0). Receptors expression profiles and their associations are presented in the Table. High HER3-HER4 co-expression was found in 35% of cases (p = 0.002). Univariate analysis did not show significant correlation of age, tumor differentiation, BMI, tobacco use and receptor expression with survival. Stage was the only variable that correlated significantly with survival (p=0.02). Conclusions: This is the first study to our knowledge examining the EGFR family expression relationships and cMet in treatment naïve resected EGA tumors. Associations between receptor expression patterns are of clinical interest for rational development of multi-targeted inhibition. Although our data do not significantly show receptor status as a prognostic factor, some receptor expression associations suggest trends towards worse survival. Larger studies are warranted for further investigation. [Table: see text]

HER2 expression and response to neoadjuvant chemoradiotherapy in esophagogastric adenocarcinoma

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Background: Targeting HER2 overexpression with trastuzumab in metastatic esophagogastric adenocarcinoma (EGA) improves survival with clinical trials currently examining the impact of HER2 inhibition in early stage disease. This study analyzed the pattern of HER2 overexpression in matched-pair tumor samples of patients (pts) undergoing neoadjuvant chemoradiotherapy (chemoRT). Methods: This analysis included pts with EGA who underwent neoadjuvant chemoRT followed by esophagectomy at the University of Florida from 2001 to 2011 who did not receive anti-HER2 therapy. Demographics, risk factors, tumor features, and outcome data were analyzed. Central blinded IHC was performed on paraffin embedded tumor specimens with HER2 expression scored as negative (-) (0, 1+), indeterminate (2+) or positive (+) (3+). Descriptive statistics, Chi-square exact test, uni and multivariate analyses were used for statistical analyses. Results: 49 pts (41M/8F) were analyzed with median age 65 years (39-87). Most tumors were stage II (55%) or III (43%). 9/49 pts (18%) had pathologic complete response (pCR), another 10/49 had near pCR or not enough tumor (NET) to examine. HER2 expression was more common in lower stages (stage I, II vs III). Baseline HER2 expression did not correlate with treatment response. Univariate analysis did not show significant correlation of age, stage, smoking, pre or post treatment HER2 expression with survival. For matched-pair samples failing to achieve pCR or NET (n=30), pre and post treatment HER2 expression profiles are presented in the Table. HER2 expression appears UP regulated in response to neoadjuvant chemoRT. Conclusions: Our study demonstrated the degree of pre-treatment HER2 expression in EGA does not predict the response to chemoRT. However, HER2 overexpression is more frequent in post treatment samples without pCR. This suggests that HER2 may be upregulated by chemoRT with unreliable concordance between pre and post treatment samples. This has implications for both early and advanced stage therapeutic interventions with targeted therapies. [Table: see text]

Hepatic preservation injury: severity of hepatitis C recurrence and survival after liver transplantation

BACKGROUND

Preservation injury in the HCV liver transplant population has been reported to correlate with poorer survival outcomes compared to preservation injury in the non-HCV liver transplant population. However, determinants of progression to cirrhosis in HCV infection remain poorly defined in this population.

AIM

This study aimed to determine if the presence and severity of preservation injury impact the acceleration of HCV recurrence and survival after liver transplant.

METHODS

We retrospectively reviewed liver transplant HCV patients over a 10-year period. Biopsies from postoperative day 7 were assessed for preservation injury and 4- and 12-month biopsies were assessed for fibrosis. Patients with Ishak fibrosis >0.8 Units/year were considered rapid fibrosers.

RESULTS

Our study group consisted of 255 patients. The mean age was 49.3 years old, 180 (70.6 %) were male, and 221 (86.7 %) were Caucasian. The incidence of preservation injury on the 7-day biopsy was 69.0 %. A strong correlation between postoperative peak AST within the first week and preservation injury was found. The overall prevalence of rapid fibrosers at 4 months, 1 and 2 years was 47.4, 75.2, and 58.9 %, respectively. The prevalence of rapid fibrosers at 4 months, 1 and 2 years between patients with or without preservation injury was not statistically significant (p = 0.39, p = 0.46, and p = 0.53, respectively). No differences were seen between patients with and without PI in terms of patient and graft survival.

CONCLUSION

In this study, the presence and severity of preservation injury were not associated with development of rapid HCV recurrence or worsening in survival.

Prognostic significance of HER2 expression and associated clinical characteristics in esophageal adenocarcinoma

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Background: The incidence of adenocarcinoma of the esophagus (EA) and gastroesophageal junction (GEJ) is on the rise. Her2Neu (HER2) is overexpressed in 20-25% of gastric cancers and is associated with poor prognosis. However, the prognostic significance of HER2 in EA/GEJ is less clear. Methods: This retrospective analysis included all sequential patients (pts) with EA or GEJ who underwent primary resection at the University of Florida from 2001 to 2011without neoadjuvant therapy or HER2 inhibition. Demographics, risk factors, tumor features, and outcome data were analyzed. Central blinded immunohistochemistry (IHC) was performed on paraffin embedded tumor specimens with HER2 expression scored as negative (-) (0 or 1+), indeterminate (2+) or positive (+) (3+). Results: 56 pts were eligible for analysis (45 M/11 F) with median age 67 years (37-83). Mean BMI was 29.6±6.6 and 43 pts (92%) had underlying Barrett’s esophagus. Most tumors (60%) were stage I (T1N0). Overall testing revealed tumors to be HER2 + (38%), indeterminate (21%) or - (41%). 50% of Stage I, 18% of stage IIA, 33% of stage IIB, and 14% of stage III tumors were HER2 + (p=0.035 for stage I compared to other stages). Underlying Barrett’s esophagus was associated with HER2 + (60 vs. 0%; p=0.045). The median follow up of the entire cohort was 2.9 years. Overall survival (OS) at 3 years was 80% for stage I, 50% for stage IA, 40% for stage IIB and 50% for stage III (p= 0.153). 3 year OS for HER2+ pts was 64% vs. 70% for HER2- (p=0.63). Univariate analysis did not show significant correlation among tobacco use, BMI, disease progression, survival and HER2 expression. Conclusions: This data suggests that HER2 overexpression is more frequent in early stage disease with underlying Barrett’s esophagus. Our data do not support HER2 as a prognostic factor in EA/GEJ. The relationship of HER2 overexpression in the development of early stage GEJ, particularly in the setting of Barrett’s, is of clinical interest. Further investigation is warranted.

Retrospective evaluation of resected ampulla of vater adenocarcinoma (AOVA): Clinicopathologic variables and long-term outcomes—REAL study

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Background: AOVA accounts for about 1% of GI cancers. 30% of patients receive curative intent resection with 5-year survival between 20-50%. Limited data are available concerning the value of adjuvant therapy. AOVA may be intestinal or biliary based on histology with each associated with a different natural history and prognosis. This study aims to characterize clinicopathologic features of this disease and associate these with outcomes. Methods: An IRB-approved retrospective review of all patients at the University of Florida between 2000-2011 was undertaken to identify patients with resected AOVA. Periampullary tumors were excluded. Independent histologic review to define intestinal versus biliary subtype and molecular phenotype (including CK 7, 19, 20, SMAD4, CDX2 and MUC1) was undertaken. Chi-square test was used to determine significance between variables. Results: 68 total patients were identified and analyzed. Clinical variables, relapse and survival data are presented (Table). For patients <70 years old, median OS was 69 months vs 13 months for patients >70 years (P=0.0115). Histologic and molecular subgroup analysis is ongoing. Conclusions: AOVA long-term outcomes are consistent with previous publications with 5-year survival of 32%. Age and stage appear to have a substantial impact on survival. Histologic and molecular analysis may further define patient subsets and will be reported. [Table: see text]

Randomized, controlled trial of standard, large-capacity versus jumbo biopsy forceps for polypectomy of small, sessile, colorectal polyps

BACKGROUND

Polypectomy with cold biopsy forceps is a frequently used technique for removal of small, sessile, colorectal polyps. Jumbo forceps may lead to more effective polypectomy because of the larger size of the forceps cup.

OBJECTIVE

To evaluate the efficiency of cold jumbo biopsy forceps compared with standard forceps for polypectomy of small, sessile, colorectal polyps.

DESIGN

Randomized, controlled trial.

SETTING

Outpatient endoscopy center.

PATIENTS

This study involved 140 patients found to have at least one eligible polyp defined as a sessile polyp measuring ≤6 mm.

INTERVENTION

Polypectomy with cold biopsy forceps.

MAIN OUTCOME MEASUREMENTS

Complete visual polyp eradication with one forceps bite.

RESULTS

In 140 patients, a total of 305 eligible polyps were detected (151 removed with jumbo forceps and 154 with standard forceps). Complete visual eradication of the polyp with one forceps bite was achieved in 78.8% of the jumbo forceps group and 50.7% of the standard forceps group (P < .0001). Biopsies from the polypectomy sites of adenomatous polyps thought to be visually completely eradicated with one bite showed a trend toward a higher complete histologic eradication rate with the jumbo forceps (82.4%) compared with the standard forceps (77.4%), but the difference did not reach statistical significance (P = .62). The withdrawal time for visual inspection of the colon and time to perform polypectomies were significantly shorter in the jumbo forceps group (mean 21.43 vs 18.23 minutes; P = .02).

LIMITATIONS

Lack of blinding to the type of forceps used.

CONCLUSION

The jumbo biopsy forceps is superior to the standard forceps in removing small, sessile polyps. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00855790.).