Digital Image Analyses in Quantitative Assessment of Key Morphologic Features of Esophageal Squamous Dysplasia and Reactive Squamous Epithelium

Introduction/Objective

Distinguishing esophageal squamous dysplasia (ESD) from reactive squamous epithelium (RSE) is a diagnostic challenge. This distinction is subjective and based upon interpretation and integration of histologic features. How the features of nuclear/cytoplasmic ratio, nuclear size, shape, and contours are used to make a diagnosis is not entirely known. The goal of our study is to quantitatively determine the performance of key histologic features using image analysis (IA) to distinguish ESD and RSE.

Methods/Case Report

The study included 50 cases of ESD (2016-19) and 50 cases of RSE (2019). One representative image (tif format) from each H&E slide was obtained at 10x via digital microscope camera. Open source software (QuPath) was utilized. Wilcoxon rank-sum tests were used to evaluate differences in measurements between ESD and RSE.

Results (if a Case Study enter NA)

In nuclear measurements, ESD had greater area (41.4μm2 vs 37.4μm2; p<0.001), greater nuclear perimeter (24.9μm vs 23.8μm; p<0.001), less circularity (0.80 vs 0.81; p=0.005), and was more elliptical (eccentricity: 0.74 vs 0.72; p<0.001) than RSE. ESD had lower nucleus/cell area ratio than RSE (0.32 vs 0.33; p=0.010). ESD was further subdivided into low grade dysplasia (LGD; n=18) and high grade dysplasia (HGD; n=37) groups and analyzed. LGD and HGD showed statistically significant differences from RSE in nuclear area (p=0.002;<0.001), perimeter (p=0.006;<0.001), and eccentricity (p=0.005;<0.001). While LGD and RSE did not show significant difference in nuclear circularity (contour) or nuclear/cell area ratio, this difference was demonstrated between HGD and RSE (p=0.007 and p=0.003).

Conclusion

Through quantitative analysis of cytologic features, our study supports the feature extraction that is performed on routine H&E is when distinguishing ESD and RSE. However, quantitative analysis offers an objective approach in this diagnostic challenge. We continue to investigate the utility of IA in diagnosis of ESD for progressive advancement in practice and diagnosis for patient care.

Key Differences in Final Pathology Compared to Pre-Operative Clinical Diagnoses in the Liver Transplant Population: Implications for Quality Improvement

Introduction/Objective

The pre-transplant clinical evaluation of patients with liver disease are critical components determining prognoses, eligibility and placement on the transplant waiting (eg. hepatocellular carcinoma (HCC) may decrease time on list), and surgical planning for the type of biliary anastomosis performed. For example, patients with Primary Sclerosing Cholangitis (PSC) are given direct liver to small bowel anastomosis, a type prone to ascending cholangitis, compared to duct to duct types in all other etiologies, and a clinical diagnoses of alcohol-induced cirrhosis impacts the patient’s and family’s psycho-social well-being. The goal of our study was to determine the frequency and types of differences in the clinical versus liver explant pathology diagnoses.

Methods

A search for “liver explant” for all in-house cases between 7/15/2019 to 7/15/2018 and 1/1/2010 to 12/31/2010 identified 105 and 108 cases, respectively. For each case, pre-operative clinical diagnoses determined by the electronic medical record was compared to pathologic diagnosis. Cases with non-concordance were divided into two groups: 1. Concordant etiology but incidental malignancy identified in explant 2. Non-concordant etiology.

Results

In the 2018–2019 group, of the 105 liver explants, 6 had concordant etiology but previously unknown HCC and 9 cases had non-concordant diagnoses. Similarly, the 2010 group, of the 108 liver explants, 6 had consistent etiology but previously unknown HCC and 8 cases non-concordant diagnoses. Of the total 17 non-concordant cases, 4 carried a pre-transplant diagnosis of PSC and were reversed to autoimmune hepatitis (2), chronic rejection, and primary biliary cholangitis on explant pathology and 3 carried a diagnosis of alcohol-induced cirrhosis and were reversed to portal tract venopathy, viral hepatitis, and alpha-1 antitrypsin.

Conclusion

There are clinically significant discordances between pre-transplant and explant diagnoses with 6% incidental malignancies and 8% etiology changes. Of particular importance for anastomoses complications and psycho-social issues are patients with a pre-operative diagnoses of PSC or alcohol whose diagnosis was changed by pathology explant assessment, respectfully. Strategies to refine and improve pre-operative liver disease diagnoses particularly with regard to biliary and alcohol diagnoses will be explored.

Impact of the Cholangiocarcinoma Component of Combined Hepatocellular/Hepatocholangiocarcinoma on Patient Survival

Introduction/Objective

The radiopathologic correlation, overall prognosis, and best management of combined hepatocellular carcinoma/cholangiocarcinoma (HCC/CC) remains uncharted territory.

Methods

We studied whether the percentage (%) of the cholangiocarcinoma (CC) component of HCC/CC impacted patient survival. A retrospective analysis was performed including all cases (18) of HCC/CC in the pathology archives from 2011–2019. Tumor beds were submitted entirely in all but 2 specimens, which were representatively sampled.

Slides from these cases were reviewed to assess % of CC. Survival was calculated from the date of diagnosis to the date of demise and censored as the date last known alive at the time of the study.

Results

13 cases were liver explants, 2 were resections, and 3 were biopsies. 13 cases were from clinical stage II patients, 2 were clinical stage IVA, and 2 were clinical stage IVB. All but one patient in the study group were males. There was no predilection for any specific tumor site. The cases were divided into three groups related to CC percentage: 0–20 (n=5), 21–40 (n=6), and >40% (n=7). AFP was variably elevated in select cases, with the highest values found in the medium and high % groups. Though there was no significant difference in overall survival among the three groups, mean and median survival trended in a downward fashion with increased % CC. Interestingly, radiology read 12 cases as HCC, 1 as intrahepatic CC, and only 1 as cholangiocarcinoma/hepatoma, atypical for HCC.

Conclusion

We conclude that there is a trend for decreased survival as % CC increases in combined HCC/CC patients, with patients with >20% CC tending to have lower survival rates. Furthermore, incongruity exists between radiologic and pathologic diagnoses of combined HCC/CC. Additional study with a larger sample size will yield more information to understand better prognosis as well as guide more accurate diagnosis of these patients.

Multiregion whole-exome sequencing of matched primary and metastatic tumors revealed genomic heterogeneity and suggested polyclonal seeding in colorectal cancer metastasis

Background

Distant metastasis accounts for 90% of deaths from colorectal cancer (CRC). Genomic heterogeneity has been reported in various solid malignancies, but remains largely under-explored in metastatic CRC tumors, especially in primary to metastatic tumor evolution.

Patients and methods

We conducted high-depth whole-exome sequencing in multiple regions of matched primary and metastatic CRC tumors. Using a total of 28 tumor, normal, and lymph node tissues, we analyzed inter- and intra-individual heterogeneity, inferred the tumor subclonal architectures, and depicted the subclonal evolutionary routes from primary to metastatic tumors.

Results

CRC has significant inter-individual but relatively limited intra-individual heterogeneity. Genomic landscapes were more similar within primary, metastatic, or lymph node tumors than across these types. Metastatic tumors exhibited less intratumor heterogeneity than primary tumors, indicating that single-region sequencing may be adequate to identify important metastasis mutations to guide treatment. Remarkably, all metastatic tumors inherited multiple genetically distinct subclones from primary tumors, supporting a possible polyclonal seeding mechanism for metastasis. Analysis of one patient with the trio samples of primary, metastatic, and lymph node tumors supported a mechanism of synchronous parallel dissemination from the primary to metastatic tumors that was not mediated through lymph nodes.

Conclusions

In CRC, metastatic tumors have different but less heterogeneous genomic landscapes than primary tumors. It is possible that CRC metastasis is, at least partly, mediated through a polyclonal seeding mechanism. These findings demonstrated the rationale and feasibility for identifying and targeting primary tumor-derived metastasis-potent subclones for the prediction, prevention, and treatment of CRC metastasis.

Assessment of 126,913 inguinal hernia repairs in the Emilia-Romagna region of Italy: analysis of 10 years

PURPOSE

Inguinal hernioplasty could be used as an indicator of the surgical quality offered in different health institutions and countries, thereby establishing a scientific basis from which the procedure can be critically assessed and ultimately improved. Quality assessment of hernioplasties could be conducted using two different methods: either analyzing dedicated regional/national databases (DD) or reviewing administrative databases (AD).

METHODS

A retrospective study of inguinal hernioplasties was carried out in the Emilia-Romagna hospitals between 2000 and 2009. Data were obtained by analyzing Hospital Discharge records regional Databases (HDD). Descriptive and multivariate statistical analysis was performed.

RESULTS

126,913 inguinal hernioplasty procedures were performed. The annual rate was on average 34 per 10,000 inhabitants. An increase of the case mix complexity and relevant changes in procedure technique were recorded. From multivariate analysis, the following independent factors related to a hospitalization longer than 1 day emerged: procedures in urgent setting (OR 3.6, CI 3.4-3.7), Charlson's score ≥2 (OR 3.4, CI 3.1-3.7), laparoscopy (OR 2.1, CI 1.9-2.3), no mesh use (OR 2.1, CI 2-2.3), age >65 years (OR 1.9, CI 1.8-1.9), associated interventions (OR 1.9, CI 1.8-1.9), bilateral hernia (OR 1.7, CI 1.6-1.8), recurrent hernia (OR 1.2, CI 1.1-1.2) and female gender (OR 1.2, CI 1.2-1.3). Factors related to non-prosthetic hernioplasty were: bilateral hernia (OR 2.7, CI 2.5-2.9), female gender (OR 1.8, CI 1.8-2.0), emergency setting (OR 1.6, CI 1.5-1.8), recurrences (OR 1.5, CI 1.4-1.6) and associated interventions (OR 1.5, CI 1.4-1.6).

CONCLUSION

Inguinal hernia should be treated as an outpatient procedure in the majority of patients. Precise guidelines are necessary. HDD demonstrated to be a good and trustworthy system to collect clinical data. When precise guidelines are lacking, legal/institutional indications play a pivotal role in shifting the hernia surgery toward a one-day surgery regimen.

Treatment of human cartilage defects by means of Nd:YAG Laser Therapy

Articular cartilage lesions represent a challenging problem for orthopaedic surgeons. The purpose of this study was to evaluate the effect of a new pulsed Nd:YAG High Intensity Laser Therapy on the regeneration of cartilage tissue in patients with traumatic lesions. Clinical, histological and immunohistochemical evaluations were performed. Ten patients affected by chondral lesions scheduled for ACI procedure, were enrolled into the study. During the chondrocyte expansion for ACI procedure, cartilage from five patients was treated by Nd:YAG High Intensity Laser Therapy (HILT group). No laser treatment was performed in the remaining patients, who were used as controls. Cartilage repair was assessed by clinicians using two different scores: Cartilage Repair Assessment (CRA) and Overall Repair Assessment (ORA). Cartilage biopsy specimens were harvested to perform histological and immunohistochemical analyses at T0 (before laser treatment) and T1 (at the end of the treatment). A significant decrease in cartilage depth was noticed in the HILT group at T1. Histological and immunohistochemical evaluations showed some regenerative processes in cartilaginous tissue in terms of high amount of proteoglycans, integration with adjacent articular cartilage and good cellular arrangement in the HILT group. By contrast, a not well organized cartilaginous tissue with various fibrous features in the control group at T0 and T1 was observed. In conclusion, the use of this new pulsed Nd:YAG HILT resulted promising in the treatment of moderate cartilage lesions markedly in the young patients.

Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery

BACKGROUND

: This study evaluated the incidence of postoperative delirium (POD) in elderly patients undergoing general surgery, the risk factors associated with POD, and its impact on hospital stay and mortality.

METHODS

: Patients aged over 65 years who had emergency or elective operations were eligible for this case-control study. Risk factors significantly associated with POD using univariable analysis were entered into multivariable analysis, to establish those independently associated with POD.

RESULTS

: A total of 351 patients (357 admissions) were enrolled in the study. The incidence of POD was 13.2 per cent (17.9 per cent for emergency operations). Independent variables associated with POD were: age above 75 years, co-morbidity, preoperative cognitive impairment, psychopathological symptoms and abnormal glycaemic control. Median length of hospital stay was 21 (range 1-75) days for patients with POD versus 8 (range 1-79) days for control patients (P < 0.001). The hospital mortality rate was 19 and 8.4 per cent respectively (P = 0.021).

CONCLUSION

: The incidence of POD is high in elderly patients for both emergency and elective surgery, leading to an increase in hospital stay and perioperative mortality. To minimize POD, associated risk factors of co-morbidity, cognitive impairment, psychopathology and abnormal glycaemic control must be identified and treated.

Impact of regionalisation of cardiac surgery in Emilia-Romagna, Italy

STUDY OBJECTIVE

Assessment of the impact of the regionalisation of cardiac surgery through the organisational form of a hub&spoke model introduced in the year 2000.

DESIGN

Case mix adjusted before (1998-1999)-after (2000-2002) comparison of: (a) in-hospital and 30 days mortality rates; (b) proportion of patients timely (within one day) referred for surgery from spoke to hub centres; (c) patients' waiting times to surgery.

SETTING

Emilia-Romagna, an Italian region with four million residents.

PATIENTS

16,512 patients aged > or =18 years and referred to cardiac surgery over the period 1998-2002.

MAIN RESULTS

Overall, taking into account differences in case mix across the whole study period, the implementation of the regionalisation policy was associated with a 22% reduction (OR: 0.79, 95%CI: 0.66 to 0.93) in in-hospital mortality rate. The corresponding figure for 30 day mortality was 18% (OR: 0.82: 95%CI: 0.69 to 0.98). The individual centres' volume of cases changed over the study period for all hospitals but two, and the biggest reduction in mortality was seen at the centre with the largest increase in caseload.

CONCLUSIONS

This study provides additional evidence on the benefit of regionalisation of cardiac surgery interventions. The system allowed each centre to reach the minimum caseload required to assure good quality of care. These findings suggest that policies aimed at increasing cooperation rather than competition among health service providers have a positive impact on quality of care. Timely referrals for surgery increased by 21% (95%CI: 1.12 to 1.31), and mean waiting times were reduced by 7.5 average days (95%CI: -10.33 to -4.71).

Immunohistochemical study of lymphocyte populations infiltrating the gastric mucosa of beagle dogs experimentally infected with Helicobacter pylori

Experimental infection of beagle dogs with Helicobacter pylori induces recruitment to the gastric mucosae of neutrophils at early stages and later of mononuclear cells that organize into lymphoid follicles. These structures become macroscopically evident and consist of peripheral CD4(+) T lymphocytes and central CD21(+) B lymphocytes. Furthermore, transient expression of interleukin-8 (IL-8) parallels the presence of neutrophils in the gastric mucosae, whereas expression of IL-6 tends to persist chronically.

A conventional beagle dog model for acute and chronic infection with Helicobacter pylori

Helicobacter pylori has been widely recognized as an important human pathogen responsible for chronic gastritis, peptic ulcers, gastric cancer, and mucosa-associated lymphoid tissue (MALT) lymphoma. Little is known about the natural history of this infection since patients are usually recognized as having the infection only after years or decades of chronic disease. Several animal models of H. pylori infection, including those with different species of rodents, nonhuman primates, and germ-free animals, have been developed. Here we describe a new animal model in which the clinical, pathological, microbiological, and immunological aspects of human acute and chronic infection are mimicked and which allows us to monitor these aspects of infection within the same individuals. Conventional Beagle dogs were infected orally with a mouse-adapted strain of H. pylori and monitored for up to 24 weeks. Acute infection caused vomiting and diarrhea. The acute phase was followed by polymorphonuclear cell infiltration, interleukin 8 induction, mononuclear cell recruitment, and the appearance of a specific antibody response against H. pylori. The chronic phase was characterized by gastritis, epithelial alterations, superficial erosions, and the appearance of the typical macroscopic follicles that in humans are considered possible precursors of MALT lymphoma. In conclusion, infection in this model mimics closely human infection and allows us to study those phases that cannot be studied in humans. This new model can be a unique tool for learning more about the disease and for developing strategies for treatment and prevention.