Paediatric Laryngeal Synovial Sarcoma: Dilemmas and Decision-Making

Primary laryngeal synovial sarcoma is a rare head and neck cancer. We describe a case of synovial sarcoma of the larynx in a previously well 9-year-old boy with a one-month history of a progressively enlarging neck lump. He was referred to our institution after incomplete surgical excision of the then undifferentiated neck mass. A partial laryngectomy including wide local excision of the residual mass was performed. An ipsilateral level I-III neck dissection was also performed concurrently. Clear re-excision margins were achieved. The neck nodes were all negative for metastatic disease. Adjuvant local radiotherapy treatment was administered to reduce the probability of local recurrence. Four years following treatment completion, the patient remains in remission with no signs of treatment-related morbidity. A review of the published literature on laryngeal synovial sarcoma was undertaken. This case represents the youngest patient to be diagnosed with the condition. Surgical excision represents the mainstay of treatment of laryngeal synovial sarcoma. At more common sites of disease, adjuvant radiotherapy has been associated with lower rates of recurrence. However, there is the potential for significant morbidity from irradiating the neck of a paediatric patient. This case report explores the challenges in treating young patients with aggressive head and neck cancers when faced with little available evidence to guide decision-making.

Dermatofibrosarcoma protuberans of the breast in pregnancy

Dermatofibrosarcoma Protuberans (DFSP) is a rare, locally aggressive fibroblastic mesenchymal neoplasm, typically derived from the dermis, with the intramammary subtype being seen infrequently. We present a case of a 40-year-old woman whom was diagnosed with an intramammary DFSP during pregnancy, whom underwent successful surgical management during her second trimester. Our case demonstrates the importance of increased clinical awareness in the diagnosis and treatment of breast DFSP with careful multidisciplinary consideration.

Melanomas in children and adolescents: Clinicopathologic features and survival outcomes

BACKGROUND

Melanomas in the first 2 decades of life are uncommon and poorly understood.

OBJECTIVE

To assess clinicopathologic features and survival of children (≤11 years) and adolescents (12-19 years) diagnosed with melanoma.

METHODS

A pooled cohort of 514 patients was analyzed (397 Dutch, 117 Australian; 62 children, 452 adolescents). Pathology reports were reevaluated to determine melanoma subtypes. Multivariable Cox models were generated for recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Melanoma subtypes were conventional melanoma (superficial spreading, nodular, desmoplastic, and acral lentiginous), spitzoid melanoma, and melanoma associated with a congenital nevus in 428, 78, and 8 patients, respectively. Ten-year RFS was 91.5% (95% confidence interval [CI], 82.4%-100%) in children and 86.4% (95% CI, 82.7%-90.3%) in adolescents (P = .32). Ten-year OS was 100% in children and 92.7% (95% CI, 89.8%-95.8%) in adolescents (P = .09). On multivariable analysis possible only for the adolescent cohort due to the small number of children, ulceration status, and anatomic site were associated with RFS and OS, whereas age, sex, mitotic index, sentinel node status and melanoma subtype were not. Breslow thickness >4 mm was associated with worse RFS.

LIMITATIONS

Retrospective study.

CONCLUSIONS

Survival rates for children and adolescents with melanomas were high. Ulceration, head or neck location and Breslow thickness >4 mm predicted worse survival in adolescents.

Association between excision margins and local recurrence in 1407 patients with primary in situ melanomas

Background

Reliable evidence to guide the management of melanoma in situ (MIS) and minimize the risk of recurrence is lacking.

Objective

To identify clinicopathological predictors of local recurrence (LR) in patients with MIS and evaluate long-term outcomes according to pathological excision margins.

Methods

A case-control study of patients with MIS treated at a large Australian melanoma treatment center from January 2008 to December 2012 was undertaken. Clinicopathological characteristics of patients who developed LR and those who did not were compared.

Results

LR developed in 34 of 1407 patients with MIS (2.5%). Median time to LR was 20 months. The primary lesion was removed with pathological margins <4 mm (P < .001) in 67.6 % of patients with LR. Four patients died of metastatic melanoma following LR. Comparing patients with pathological margins <4 mm and ≥4 mm, the former were older (>60y, P < .001), more frequently had MIS on the head or neck (P < .001), had a greater LR rate (P < .001), and had a higher mortality from all causes (P < .001).

Limitations

Retrospective, single-institution study.

Conclusions

Pathological margins of ≥4 mm should be considered for patients with MIS who are treated with standard surgical excision and assessed by examining serial slices taken from the formalin-fixed, paraffin-embedded specimen.

Pathologist initiated reflex BRAF mutation testing in metastatic melanoma: experience at a specialist melanoma treatment centre

Testing for BRAF mutations in metastatic melanoma is pivotal to identifying patients suitable for targeted therapy and influences treatment decisions regarding single agent versus combination immunotherapy. Knowledge of BRAF V600E immunohistochemistry (IHC) results can streamline decisions during initial oncology consultations, prior to DNA-based test results. In the absence of formal guidelines that require pathologist initiated ('reflex') BRAF mutation testing, our institution developed a local protocol to perform BRAF V600E IHC on specimens from all stage III/IV melanoma patients when the status is otherwise unknown. This study was designed to evaluate the application of this protocol in a tertiary referral pathology department. A total of 408 stage III/IV melanoma patients had tissue specimens accessioned between 1 January and 31 March in three consecutive years (from 2019 to 2021), reported by 32 individual pathologists. The BRAF mutation status was established by pathologists in 87% (352/408) of cases. When a prior BRAF mutation status was previously known, as confirmed in linked electronic records (202/408), this status had been communicated by the clinician on the pathology request form in 1% of cases (3/202). Pathologists performed BRAF V600E IHC in 153 cases (74% of cases where the status was unknown, 153/206) and testing was duplicated in 5% of cases (20/408). Reflex BRAF IHC testing was omitted in 26% of cases (53/206), often on specimens with small volume disease (cytology specimens or sentinel node biopsies) despite adequate tissue for testing. Incorporating BRAF IHC testing within routine diagnostic protocols of stage III/IV melanoma was both feasible and successful in most cases. Communication of a patient's BRAF mutation status via the pathology request form will likely improve implementation of pathologist initiated BRAF mutation testing and may result in a reduction of duplicate tests. To improve pathologist reflex testing rates, we advocate for the use of an algorithmic approach to pathologist initiated BRAF mutation testing utilising both IHC and DNA-based methodologies for stage III/IV melanoma patients.

Lack of association between anatomical sites of scalp melanomas and brain metastases does not support direct vascular spread

Primary scalp melanomas are associated with a higher rate of brain metastasis than primary cutaneous melanomas occurring at other head and neck and body sites, but the reason is unclear. Spread to brain parenchyma via emissary veins draining from the scalp to dural sinuses has been suggested. We sought to examine the locations of metastases from primary scalp and nonscalp head and neck melanomas to determine whether there was anatomical evidence supporting direct venous spread to the brain. Data from patients who developed distant metastases from cutaneous head and neck melanomas (CHNMs) between 2000 and 2018 were analyzed. Anatomical sites of primary scalp melanomas and their respective intracranial metastases were compared. Times to first brain and nonbrain metastases were investigated for scalp and nonscalp primary CHNMs. Of 693 patients with CHNMs, 244 developed brain metastases: 109 (44.7%) had scalp primaries and 135 (55.3%) had nonscalp primaries. There was no significant association between anatomical sites of scalp primary melanomas and brain metastases (Cramer's V = 0.21; Chi-square P = 0.63). Compared with nonscalp CHNMs, scalp melanomas had no greater propensity for the brain as the first distant metastatic site ( P = 0.52) but had a shorter time to both brain metastasis (76.3 vs. 168.5 months; P < 0.001) and nonbrain metastasis (22.6 vs. 35.8 months; P < 0.001). No evidence was found to support a direct vascular pathway for metastatic spread of scalp melanomas to the brain. The increased incidence of brain metastases from scalp melanomas is probably driven by aggressive biological mechanisms.

Validation of an Accurate Automated Multiplex Immunofluorescence Method for Immuno-Profiling Melanoma

Multiplex immunofluorescence staining enables the simultaneous detection of multiple immune markers in a single tissue section, and is a useful tool for the identification of specific cell populations within the tumour microenvironment. However, this technology has rarely been validated against standard clinical immunohistology, which is a barrier for its integration into clinical practice. This study sought to validate and investigate the accuracy, precision and reproducibility of a multiplex immunofluorescence compared with immunohistochemistry (IHC), including tissue staining, imaging and analysis, in characterising the expression of immune and melanoma markers in both the tumour and its microenvironment. Traditional chromogenic IHC, single-plex immunofluorescence and multiplex immunofluorescence were each performed on serial tissue sections of a formalin-fixed paraffin-embedded (FFPE) tissue microarray containing metastatic melanoma specimens from 67 patients. The panel included the immune cell markers CD8, CD68, CD16, the immune checkpoint PD-L1, and melanoma tumour marker SOX10. Slides were stained with the Opal^™ 7 colour Kit (Akoya Biosciences) on the intelliPATH autostainer (Biocare Medical) and imaged using the Vectra 3.0.5 microscope. Marker expression was quantified using Halo v.3.2.181 (Indica Labs). Comparison of the IHC and single-plex immunofluorescence revealed highly significant positive correlations between the cell densities of CD8, CD68, CD16, PD-L1 and SOX10 marker positive cells (Spearman’s rho = 0.927 to 0.750, p < 0.0001). Highly significant correlations were also observed for all markers between single-plex immunofluorescence and multiplex immunofluorescence staining (Spearman’s rho >0.9, p < 0.0001). Finally, correlation analysis of the three multiplex replicates revealed a high degree of reproducibility between slides (Spearman’s rho >0.940, p < 0.0001). Together, these data highlight the reliability and validity of multiplex immunofluorescence in accurately profiling the tumour and its associated microenvironment using FFPE metastatic melanoma specimens. This validated multiplex panel can be utilised for research evaluating melanoma and its microenvironment, such as studies performed to predict patient response or resistance to immunotherapies.

CD147 mediates intrahepatic leukocyte aggregation and determines the extent of liver injury

Background

Chronic inflammation is the driver of liver injury and results in progressive fibrosis and eventual cirrhosis with consequences including both liver failure and liver cancer. We have previously described increased expression of the highly multifunctional glycoprotein CD147 in liver injury. This work describes a novel role of CD147 in liver inflammation and the importance of leukocyte aggregates in determining the extent of liver injury.

Methods

Non-diseased, progressive injury, and cirrhotic liver from humans and mice were examined using a mAb targeting CD147. Inflammatory cell subsets were assessed by multiparameter flow cytometry.

Results

In liver injury, we observe abundant, intrahepatic leukocyte clusters defined as ≥5 adjacent CD45⁺ cells which we have termed “leukocyte aggregates”. We have shown that these leukocyte aggregates have a significant effect in determining the extent of liver injury. If CD147 is blocked in vivo, these leukocyte aggregates diminish in size and number, together with a marked significant reduction in liver injury including fibrosis. This is accompanied by no change in overall intrahepatic leukocyte numbers. Further, blocking of aggregation formation occurs prior to an appreciable increase in inflammatory markers or fibrosis. Additionally, there were no observed, “off-target” or unpredicted effects in targeting CD147.

Conclusion

CD147 mediates leukocyte aggregation which is associated with the development of liver injury. This is not a secondary effect, but a cause of injury as aggregate formation proceeds other markers of injury. Leukocyte aggregation has been previously described in inflammation dating back over many decades. Here we demonstrate that leukocyte aggregates determine the extent of liver injury.

The effect of in vitro phorone exposure on glutathione content and T cell antigen receptor (CD3)-stimulated calcium mobilization in murine splenic T lymphocytes

An increase in cytosolic free calcium ([Ca(2+)](i)) is one of the earliest events to occur in T lymphocytes following stimulation of the transmembrane T cell receptor/CD3 complex (TCR/CD3). This [Ca(2+)](i) mobilization has been found to be sensitive to intracellular thiol redox status, which in turn is modulated by cellular glutathione (GSH) content. We have previously reported that GSH depletion, by treatment with either the alpha, beta-carbonyl diethyl maleate or the aromatic halo-compound 1-chloro-2,4-dinitrobenzene, correlates with decreased [Ca(2+)](i) mobilization in anti-CD3 monoclonal antibody (mAb)-stimulated human peripheral blood lymphocytes (HPBL). This prompted us to determine whether this correlation between GSH content and TCR/CD3 signal transduction capability was also present in murine lymphocytes, since the mouse model is often used as a surrogate for the human immune system. The results presented here demonstrate that in vitro treatment with the alpha, beta-carbonyl phorone dose-dependently depletes intracellular GSH in murine splenic T lymphocytes. Both CD4(+) and CD8(+) T lymphocytes depleted of GSH by greater than 40% were found to have a decreased [Ca(2+)](i) mobilization following anti-CD3 mAb stimulation. Similar to what has been described for HPBL, these results indicate that the cellular GSH status influences the initial response of murine T lymphocytes to TCR/CD3 stimulation.

Splenocyte glutathione and CD3-mediated cell proliferation are reduced in mice fed a protein-deficient diet

Protein-energy malnutrition (PEM) is associated with decreased host immune defense. Glutathione (GSH) status is reported to be decreased in PEM, and GSH is important for lymphocyte function. The objective of the present study was to investigate the effects of PEM and dietary repletion (RP) on GSH status in various tissues and splenocytes and on CD3-mediated calcium mobilization and cell proliferation of splenic T-lymphocytes. For the PEM model, mice were fed a 0.5% protein diet (LP group) for 4 or 6 wk, and control mice were fed a 15% protein diet (CP group). In the RP study, LP mice were fed the 15% protein diet for 3 d, 1 wk, 2 wk or 3 wk (RP groups). Glutathione concentrations were significantly lower in liver, lung, heart and spleen of LP mice compared with CP mice at 4 and 6 wk. Splenocytes from LP mice were significantly lower in number and had a lower intracellular GSH concentration, depressed CD3-stimulated T-lymphocyte proliferation in culture media without thiol supplementation (2-mercaptoethanol), and enhanced CD3-stimulated proliferation in thiol-supplemented culture media compared with splenocytes from CP mice. CD3-stimulated calcium mobilization was significantly lower in CD8+, but not CD4+, splenocytes from LP mice. Within 1 wk of dietary repletion, splenocyte GSH concentration was normal and splenocyte numbers were greater, and in vitro sensitivity of CD3-stimulated T-lymphocyte proliferation to thiol was lower, compared with LP mice. Glutathione status in vivo and thiol supplementation in vitro seem to modulate the signal transduction pathway for T-lymphocyte proliferation in mice with PEM.

Potassium-stimulated efflux of radiolabeled products formed from L-[14C(U)]-glutamine in vitro by the saccule of the rainbow trout (Salmo gairdnerii R.)

Samples of saccular macula from the rainbow trout were incubated in vitro with uniformly-labeled L-[14C]-glutamine, and radiolabeled products, released by potassium-induced depolarization in the presence of calcium, were examined. Most of the effluxed radioactivity was distributed in six (of 17) thin-layer chromatographic fractions. Fractions corresponding to aspartate and glutamate showed highly significant increases in radioactivity (as percent of total recovered radioactivity) during high-potassium treatment. Radioactivity in a fraction with an RF close to that of ornithine also significantly increased during potassium, and dropped sharply after potassium. The origins of the thin-layer fractions, with respect to sensory and neural elements in the saccular macula samples, are discussed.

Intranasal glomus tumor

The glomus tumor, or glomangioma, is a hyperplastic or hamartomatous lesion of the glomus body. It is composed of vascular channels surrounded by characteristic "epithelioid" cells, which are probably derived from smooth muscle. Glomus tumors rarely occur in the head and neck. We encountered the fifth documented case, to our knowledge, of a glomus tumor presenting in the nasal cavity. Although the lesion in this case was asymptomatic, intranasal glomus tumors producing nasal obstruction, pain, and epistaxis have been described. The complete excision of a glomus tumor normally cures the condition.