Comparison of four different displays for identification of select pathologic features extracted from whole slide images of surgical pathology cases

BACKGROUND

The establishment of minimum standards for display selection for the whole slide image (WSI) interpretation has not been fully defined. Recently, pathologists have increasingly preferred using remote displays for clinical diagnostics. Our study aims to assess and compare the performance of three fixed work displays and one remote personal display in accurately identifying ten selected pathologic features integrated into WSIs.

DESIGN

Hematoxylin and eosin-stained glass slides were digitized using Philips scanners. Seven practicing pathologists and three residents reviewed ninety WSIs to identify ten pathologic features using the LG, Dell, and Samsung and an optional consumer-grade display. Ten pathologic features included eosinophils, neutrophils, plasma cells, granulomas, necrosis, mucin, hemosiderin, crystals, nucleoli, and mitoses.

RESULTS

The accuracy of the identification of ten features on different types of displays did not significantly differ among the three types of "fixed" workplace displays. The highest accuracy was observed for the identification of neutrophils, eosinophils, plasma cells, granuloma, and mucin. On the other hand, a lower accuracy was observed for the identification of crystals, mitoses, necrosis, hemosiderin, and nucleoli. Participant pathologists and residents preferred the use of larger displays (>30″) with a higher pixel count, resolution, and luminance.

CONCLUSION

Most features can be identified using any display. However, certain features posed more challenges across the three fixed display types. Furthermore, the use of a remote personal consumer-grade display chosen according to the pathologists' preference showed similar feature identification accuracy. Several factors of display characteristics seemed to influence pathologists' display preferences such as the display size, color, contrast ratio, pixel count, and luminance calibration. This study supports the use of standard "unlocked" vendor-agnostic displays for clinical digital pathology workflow rather than purchasing "locked" and more expensive displays that are part of a digital pathology system.

A Comparison of Single Dimension and Volume Measurements in the Risk Stratification of Pancreatic Cystic Lesions

The incidence of pancreatic cystic lesions (PCLs) has been rising due to improvements in imaging. Of these, intraductal papillary mucinous neoplasms (IPMNs) are the most common and are thought to contribute to almost 20% of pancreatic adenocarcinomas. All major society guidelines for the management of IPMNs use size defined by maximum diameter as the primary determinant of whether surveillance or surgical resection is recommended. However, there is no consensus on how these measurements should be obtained or whether a single imaging modality is superior. Furthermore, the largest diameter may fail to capture the complexity of PCLs, as most are not perfectly spherical. This article reviews current PCL measurement techniques in CT, MRI, and EUS and posits volume as a possible alternative to the largest diameter.

Wrong Tissue in Block

OBJECTIVES

Maintaining specimen identity during surgical pathology tissue processing is critical. Epic Beaker Laboratory Information System requires sequential scanning of specimen label and grossed blocks (block confirmation) to ensure specimen identity. We report our institution's experience with wrong tissue in block (WTIB) grossing errors before and after adopting block confirmation.

METHODS

During the first 18 months of Beaker implementation, block confirmation was not required. We then mandated block confirmation for a 3-month period. To ensure compliance, we then built a "hard stop" feature that prevents scanning any unconfirmed blocks onto a packing list. We reviewed WTIB incidents pre- and postimplementation of these solutions.

RESULTS

Before using block confirmation, we had WTIB incidents involving 17 (0.043%) of 38,848 cases. When we mandated block confirmation use, we had WTIB involving 2 (0.043%) of 4,646 cases. After implementing the hard stop feature, we had WTIB incidents involving 2 (0.005%) of 42,411 cases. Overall, there was an 88.4% (0.043% vs 0.005%; P < .001) reduction in WTIB incidents using block confirmation with a hard stop.

CONCLUSIONS

Beaker is a customizable platform that can be tailored to a laboratory's workflow. By using barcoding, implementing custom-built features, and improving workflow protocols, we significantly reduced WTIB errors.

Associations of mammographic breast density with breast stem cell marker-defined breast cancer subtypes

PURPOSE

High mammographic breast density is a strong, well-established breast cancer risk factor. Whether stem cells may explain high breast cancer risk in dense breasts is unknown. We investigated the association between breast density and breast cancer risk by the status of stem cell markers CD44, CD24, and ALDH1A1 in the tumor.

METHODS

We included 223 women with primary invasive or in situ breast cancer and 399 age-matched controls from Mayo Clinic Mammography Study. Percent breast density (PD), absolute dense area (DA), and non-dense area (NDA) were assessed using computer-assisted thresholding technique. Immunohistochemical analysis of the markers was performed on tumor tissue microarrays according to a standard protocol. We used polytomous logistic regression to quantify the associations of breast density measures with breast cancer risk across marker-defined tumor subtypes.

RESULTS

Of the 223 cancers in the study, 182 were positive for CD44, 83 for CD24 and 52 for ALDH1A1. Associations of PD were not significantly different across t marker-defined subtypes (51% + vs. 11-25%: OR 2.83, 95% CI 1.49-5.37 for CD44+ vs. OR 1.87, 95% CI 0.47-7.51 for CD44-, p-heterogeneity = 0.66; OR 2.80, 95% CI 1.27-6.18 for CD24+ vs. OR 2.44, 95% CI 1.14-5.22 for CD24-, p-heterogeneity = 0.61; OR 3.04, 95% CI 1.14-8.10 for ALDH1A1+ vs. OR 2.57. 95% CI 1.30-5.08 for ALDH1A1-, p-heterogeneity = 0.94). Positive associations of DA and inverse associations of NDA with breast cancer risk were similar across marker-defined subtypes.

CONCLUSIONS

We found no evidence of differential associations of breast density with breast cancer risk by the status of stem cell markers. Further studies in larger study populations are warranted to confirm these associations.

Tumour lysis syndrome following eribulin for metastatic uterine leiomyosarcoma

A middle-aged woman with a history of leiomyosarcoma of the uterus treated with surgery and adjuvant chemotherapy suffered a bulky metastatic recurrence 1 year later. She elected treatment with palliative eribulin, presenting with acute renal failure and electrolyte abnormalities consistent with tumour lysis syndrome on cycle 1 day 8. Despite aggressive supportive care and treatment including intravenous hydration, bicarbonate and rasburicase, she continued to decline, ultimately foregoing haemodialysis in favour of palliative care and passed away in the hospital.

An "accidental" discovery: Incidentally found metanephric adenofibroma in a 5-year-old male trauma patient

Metanephric adenofibroma is a rare pediatric renal tumor, which should be considered in cases of solid renal lesions that mimic Wilms tumor on both imaging and histology. We present a case of an incidentally found left renal lesion on a trauma computed tomography scan in a 5-year-old male patient. The patient underwent total nephrectomy, and the diagnosis of metanephric adenofibroma was made on histology. Radiologists should consider this entity in the differential for an incidentally found solitary renal mass in a pediatric patient. Prompting the pathologic diagnosis of this entity can spare patients from unnecessary chemotherapy and allow for nephron-sparing surgery.

MYC amplification in subtypes of breast cancers in African American women

Background

MYC overexpression is associated with poor prognosis in breast tumors (BCa). The objective of this study was to determine the prevalence of MYC amplification and associated markers in BCa tumors from African American (AA) women and determine the associations between MYC amplification and clinico-pathological characteristics.

Methods

We analyzed 70 cases of well characterized archival breast ductal carcinoma specimens from AA women for MYC oncogene amplification. Utilizing immune histochemical analysis estrogen receptor (ER), progesterone receptor (PR), and (HER2/neu), were assessed. Cases were Luminal A (ER or PR+, Ki-67 < 14%), Luminal B (ER or PR+, Ki-67 = > 14% or ER or PR+ HER2+), HER2 (ER-, PR-, HER2+), and Triple Negative (ER-, PR-, HER2-) with basal-like phenotype. The relationship between MYC amplification and prognostic clinico-pathological characteristics was determined using chi square and logistic regression modeling.

Results

Sixty-five (97%) of the tumors showed MYC gene amplification (MYC: CEP8 > 1). Statistically significant associations were found between MYC amplification and HER2-amplified BCa, and Luminal B subtypes of BCa (p < 0.0001), stage (p < 0.001), metastasis (p < 0.001), and positive lymph node status (p = 0.039). MYC amplification was associated with HER2 status (p = 0.01) and tumor size (p = 0.01). High MYC amplification was seen in grade III carcinomas (MYC: CEP8 = 2.42), pre-menopausal women (MYC: CEP8 = 2.49), PR-negative status (MYC: CEP8 = 2.42), and ER-positive status (MYC: CEP8 = 2.4).

Conclusions

HER2 positive BCas in AA women are likely to exhibit MYC amplification. High amplification ratios suggest that MYC drives HER2 amplification, especially in HER2 positive, Luminal B, and subtypes of BCa.

Clinical significance and management of Barrett’s esophagus with epithelial changes indefinite for dysplasia

Barrett’s esophagus (BE) is defined as the extension of salmon-colored mucosa into the tubular esophagus ≥ 1 cm proximal to the gastroesophageal junction with biopsy confirmation of intestinal metaplasia. Patients with BE are at increased risk of esophageal adenocarcinoma (EAC), and undergo endoscopic surveillance biopsies to detect dysplasia or early EAC. Dysplasia in BE is classified as no dysplasia, indefinite for dysplasia (IND), low grade dysplasia (LGD) or high grade dysplasia (HGD). Biopsies are diagnosed as IND when the epithelial abnormalities are not sufficient to diagnose dysplasia or the nature of the epithelial abnormalities is uncertain due to inflammation or technical issues. Specific diagnostic criteria for IND are not well established and its clinical significance and management has not been well studied. Previous studies have focused on HGD in BE and led to changes and improvement in the management of BE with HGD and early EAC. Only recently, IND and LGD in BE have become focus of intense study. This review summarizes the definition, neoplastic risk and clinical management of BE IND.

Metabolic profile of triple-negative breast cancer in African-American women reveals potential biomarkers of aggressive disease

Expression of estrogen receptor (ER), progesterone receptor (PR), and the human epidermal growth factor receptor 2 (HER2) can subdivide breast carcinomas into clinically meaningful classes. Cancers lacking expression of all three of these receptors (triple-negative breast cancer; TNBC) is of particular interest for molecular research because these tumors currently have no effective targets for therapy. Furthermore, TNBCs are relatively more prevalent among African-American women and can account for some of the health disparities associated with breast cancer. We approached a molecular understanding of how TNBC differs from ER(+) breast cancer through a comprehensive gas chromatography (GC)-mass spectrometry (MS) and liquid chromatography (LC)/MS/MS-based and unbiased metabolomic analysis of a series of breast carcinomas from African-American patients. Remarkably, global metabolomic profiling of tumor tissues identified a total of 418 distinct metabolites, out of which 133 (31.8%) were shown to differ between the ER(+) and TNBC tumors with statistical probability of p<0.05. Specific biochemical pathways affected included those reflecting general increases in energy metabolism and transmethylation in the TNBC tumors when compared to ER(+) tumors. Additionally, biochemicals associated with increased proliferation, redox balance and the recently proposed oncometabolites, sarcosine and 2-hydroxyglutarate, were also detected at higher levels in the TNBC versus ER(+) tumors. These studies demonstrate that TNBC tumors have metabolic signatures that distinguish them from ER(+) tumors and suggest that distinctive metabolic characteristics of these tumors might offer new targets for treatment.

Strong association of fascin expression with triple negative breast cancer and basal-like phenotype in African-American women

BACKGROUND

Fascin, an actin bundling protein, plays a critical role in cell motility due to formation of actin rich protrusions called filopodia, important in cell migration, invasion and metastatic spread. Fascin overexpression has been associated with epithelial to mesenchymal transition and correlates with progression and unfavourable prognosis in breast carcinoma.

OBJECTIVE

To evaluate fascin expression by immunohistochemistry and correlate the expression pattern with clinicopathological parameters in breast cancer in African-American (AA) women, in whom triple negative breast cancer (TNBC), an aggressive subtype, is more prevalent.

METHODS

Tissue microarrays were constructed from formalin-fixed, paraffin-embedded blocks of tumour tissue from primary breast carcinomas in 202 AA women. Immunohistochemical detection of fascin was correlated with four major subtypes of breast carcinoma (luminal A, luminal B, human epidermal growth factor receptor 2 and triple negative (TN)) and other clinicopathological factors, including age, grade, tumour size, stage, regional lymph node status and survival.

RESULTS

We observed a significant association between fascin expression and TN subtype, oestrogen receptor (ER) negativity, progesterone receptor (PR) negativity, Elston-Nottingham (EN) grade 3 and decreased overall survival. There was also a significant association between expression of CK 5/6, a marker of basal-like phenotype, and fascin expression.

CONCLUSION

These results suggest that fascin is a marker for TN subtype having a basal-like phenotype and decreased overall survival. Fascin may represent a target for therapy in TNBC in AA women.

Sepsis caused by Mycobacterium terrae complex in a patient with sickle cell disease

Infections are a significant cause of morbidity and mortality in patients with sickle cell disease. Loss of splenic function in these patients makes them highly susceptible to some bacterial infections. Non-tuberculous mycobacterial infections in patients with sickle cell disease are extremely rare and only two cases have been reported previously. We describe a case of sepsis caused by non-tuberculous mycobacterium, Mycobacterium terrae complex in a patient with febrile sickle cell disease. M terrae complex is a rare clinical pathogen and this is the first reported case of sepsis secondary to this organism in a patient with sickle cell disease. The patient responded to imipenem and amikacin therapy.

Extensive peritoneal carcinomatosis secondary to renal cell carcinoma with sarcomatoid and rhabdoid differentiation

Renal cell carcinoma (RCC), the most common malignancy of kidney, originates from renal tubular epithelium. It is subclassified based on histological and molecular features. Rarely, RCC can show focal to extensive sarcomatoid or rhabdoid differentiation. RCC with extensive sarcomatoid differentiation and no identifiable epithelial component is designated as unclassified RCC with sarcomatoid differentiation. Presence of sarcomatoid or rhabdoid differentiation is associated with poor prognosis. We describe autopsy findings in a case of RCC with extensive sarcomatoid and focal rhabdoid differentiation presenting with malignant ascites secondary to peritoneal carcinomatosis and multiorgan metastasis.

Angiolipoma: rare cause of adult ileoileal intussusception

Intussusception in adults is rare and more common in the paediatric population. Clinically, most adult patients have chronic non-specific symptoms due to partial obstruction. In contrast, most paediatric patients present with the classic triad of abdominal pain, vomiting and blood in stool. Adult intussusception is commonly associated with an organic aetiology, most likely a benign or malignant neoplasm as a lead point of intussusception. We describe a case of a 29-year-old woman with subacute presentation due to ileoileal intussusception secondary to a polypoid submucosal angiolipoma. Angiolipoma is a benign lesion composed of mature adipose tissue and thin-walled capillaries. The presence of thin-walled vessels differentiates it from a lipoma. Angiolipomas of the small intestine are extremely rare with very few reported cases. This case not only demonstrates an unusual benign lesion as a cause of intussusception, but also illustrates an atypical clinical presentation in adults with intussusception.

Scrotal mass and unilateral lung masses with pleural effusion mimicking metastatic testicular malignancy: an unusual presentation of sarcoidosis

Involvement of the genitourinary tract by sarcoidosis may present with a scrotal mass, mimicking infection or malignancy. Sarcoidosis is a systemic granulomatous disease that affects patients of both sexes worldwide. Sarcoidosis of the genitourinary tract is rare. We describe a case of a 33-year-old African-American man who presents with a scrotal mass, mediastinal mass, unilateral lung masses and pleural effusion mimicking testicular malignancy with pulmonary metastases. The histopathological examination of the right testis and lung biopsy revealed granulomatous inflammation consistent with sarcoidosis. Genitourinary sarcoidosis must be a diagnostic consideration, especially in an African-American patient with a scrotal mass. There is a possible association between sarcoidosis and testicular malignancy; hence, underlying malignancy should always be ruled out. Serum tumour markers, ACE, a biopsy of the accessible tissue and intraoperative frozen section analysis aid in establishing the diagnosis of sarcoidosis and leading to appropriate management.

Abstract 1699: Breast cancer protein markers in African Americans

The purpose of this study is to characterize protein markers in African American breast tumors that correspond to different tumor subtypes, recurrence, and survival. Tissue microarrays (TMA) have been used because they have the advantage of analyzing numerous samples on a single slide and can be used in clinical pathology laboratories. Protein markers that have been used are estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (Her2), cyclin A2, cytokeratin 5, vimentin, Bcl2, and Ki67. TMA have been prepared and stained for proteins that will distinguish 5 tumor subtypes: luminal A (ER+ and/or PR+ Her2-); luminal B (ER+ and/or PR+ Her2- Cyclin A2+ and/or Ki67+); luminal B Her2+ (ER+ and/or PR+ Her2+); Her2+ (ER- PR- Her2+), and triple negative (ER- PR- Her2-). These subtypes are known to be associated with different relapse-free survival and overall survival. Luminal B tumors have the same ER+PR+HER2- profile as luminal A tumors; however, luminal B tumors have a poor prognosis, whereas luminal A tumors have the best prognosis of all 5 subtypes. Luminal B tumors can be distinguished from luminal A tumors by staining for cell cycle proteins Cyclin A2 or Ki67, which promote cell proliferation. Cyclin A2 was more frequently expressed than Ki67 in tumors with poor prognosis such as luminal B (ER+PR+HER-) and ER-PR-HER2- (triple negative) tumors. Therefore, Cyclin A2+ may better serve to identify luminal B and triple negative tumors with a poor prognosis and thus aid physicians in treatment decisions. The RASSF1A protein has been reported to inhibit the transcription of Cyclin A2. Methylation of the RASSF1A promoter is expected to decrease RASSF1A transcription and thereby increase Cyclin A2 transcription and protein levels. Significantly increased levels of RASSF1A methylation have been observed in this laboratory with AA ER-PR-HER- breast cancer patients compared to mammoplasty samples. Thus, increased Cyclin A2 protein staining correlated with increased RASSF1A methylation. This is one molecular explanation for elevated cyclin A2 protein levels in triple negative tumors. Discovery of molecular markers and subtypes that are most prevalent in African Americans could lead to a better treatment, targets for therapy, and understanding of the factors contributing to higher mortality in this group compared to other groups.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1699. doi:1538-7445.AM2012-1699