The Trends of Immunohistochemistry for Tissue-Invasive Cytomegalovirus in Gastrointestinal Mucosal Biopsies: A Large Single Academic Center Study

CONTEXT.—

Cytomegalovirus (CMV) immunohistochemistry (IHC) is the most widely used method to diagnose CMV infection/reactivation in tissues in a pathology laboratory.

OBJECTIVE.—

To improve the efficiency of CMV IHC testing by evaluating immunopositive staining trends of tissue-invasive CMV in the gastrointestinal system.

DESIGN.—

A total of 1479 individual orders for CMV IHC on gastrointestinal biopsy specimens from 2016 to 2018 were included. The analysis was performed to identify the significant factors contributory to CMV-positive test results.

RESULTS.—

The overall positivity rate of CMV IHC in our institution is 4.73% (70 of 1479). The positivity rate from physician-requested and pathologist-initiated tests was significantly different (7.54% versus 3.83%, P = .004). Cases with severe inflammation showed a higher positive CMV rate than those with mild inflammation (5.37% versus 2.60%, P = .04). Cytomegalovirus positivity in biopsies from posttransplant patients, inflammatory bowel disease, human immunodeficiency virus (HIV)/common variable immunodeficiency (CVID), cancer, and others was 19.69%, 3.84%, 23.33%, 9.00%, and 2.84%, respectively. The positivity rate among posttransplant, HIV/CVID, or cancer patients was significantly higher than in other populations. Cases tested with multiple tissue blocks generated a higher positivity rate than those with a single block (7.77% versus 3.23%, P < .001). Testing 3 to 4 blocks per case almost tripled the positive CMV detection rate (9.04%). Interestingly, using 5 or more blocks did not further ameliorate the positive CMV detection rate.

CONCLUSIONS.—

The data revealed that physician request, immunosuppression, multiple blocks, and severe inflammation were strongly related to positive CMV IHC detection rate. These findings might provide value in helping pathologists manage CMV IHC testing more efficiently.

Lessons Learned From an Anatomic Pathology Department in a Large Academic Medical Center at the Epicenter of COVID-19

Many state-wide, city-wide, and hospital-wide changes have been implemented due to the ongoing COVID-19 crisis. We describe lessons learned in an anatomic pathology division at a tertiary care center during the peak of the COVID-19 pandemic in the hopes that knowledge of our experiences can benefit other pathology departments as they encounter this pandemic. Five categories that are critical in strategic planning for the COVID-19 pandemic are discussed: workload, departmental policy revisions, impact on faculty, workforce staffing, and impact on educational programs, including residency and fellowship training. Although the volume of COVID-19 testing had grown placing increased demands on the clinical pathology laboratory, the volume of anatomic pathology cases had declined during the COVID-19 peak. Lessons learned were widespread including changes in the anatomic pathology workflow due to declining surgical and cytologic case volumes and increases in autopsy requests. Modifications were required in gross room policies, levels of personal protective equipment, and workforce. Travel and meeting policies were impacted. Adaptations to residency and fellowship programs were vast and included innovations in didactic and interactive education. We must learn from our experiences thus far in order to move forward, and we hope that our experiences in an anatomic pathology department in the epicenter of the COVID-19 pandemic can help other pathology departments across the country.

The OSPE

OBJECTIVES

Resident assessment tends to consist of multiple-choice examinations, even in nuanced areas, such as quality assurance. Internal medicine and many other specialties use objective structured clinical examinations, or OSCEs, to evaluate residents. We adapted the OSCE for pathology, termed the Objective Structured Pathology Examination (OSPE).

METHODS

The OSPE was used to evaluate first- and second-year residents over 2 years. The simulation included an anatomic pathology sign-out session, where the resident could be evaluated on diagnostic skills and knowledge of key information for cancer staging reports, as well as simulated frozen-section analysis, where the resident could be evaluated on communication skills with a "surgeon." The OSPE also included smaller cases with challenging quality issues, such as mismatched slides or gross description irregularities. All cases were scored based on the Pathology Milestones created by the Accreditation Council for Graduate Medical Education.

RESULTS

Using this OSPE, we were able to demonstrate that simulated experiences can be an appropriate tool for standardized evaluation of pathology residents.

CONCLUSIONS

Yearly evaluation using the OSPE could be used to track the progress of both individual residents and the residency program as a whole, identifying problem areas for which further educational content can be developed.

Pathologic Evaluation of Breast Tissue From Transmasculine Individuals Undergoing Gender-Affirming Chest Masculinization

Context.—

Bilateral mastectomy for chest masculinization is one of the gender-affirming procedures for transmasculine individuals.

Objective.—

To optimize gross handling protocols and assess histopathologic findings in transmasculine breast tissue specimens.

Design.—

We identified all gender-affirming mastectomies from 2015 to 2018. We sequentially identified reduction mammoplasty (RM) cases for macromastia from the same period as control. Significant findings were defined as atypical ductal or lobular hyperplasia (ADH, ALH), ductal or lobular carcinoma in situ (DCIS, LCIS), or invasive carcinoma.

Results.—

Significant findings were present in 6 of 211 gender-affirming mastectomies (2.8%) as follows: ADH (n = 5) and LCIS together with ALH (n = 1). By comparison, 19 of 273 RM specimens (7%) yielded significant findings as follows: ALH (n = 11), ADH (n = 4), LCIS (n = 2), DCIS (n = 1), and invasive lobular carcinoma (n = 1). In the gender-affirming group, 142 transmen underwent androgen therapy before surgery, of whom 2 had significant pathologic findings. Thirty and 41 individuals had a family history of breast cancer in the gender-affirming and RM group, of whom 1 and 3 individuals had significant pathologic findings, respectively.

Conclusions.—

Our study demonstrates that we handle transmasculine mastectomy specimens by examining 2.8 times more slides on average than for RMs, with a 2.5 times lower rate of significant pathologic findings. Prior family history of breast cancer or the use of androgen therapy before surgery in gender-affirming individuals did not increase the risk of identifying significant breast lesions. We recommend submitting 4 tissue blocks per mastectomy for individuals undergoing gender-affirming breast surgery.

DNA amplification for direct detection of HIV-1 in DNA of peripheral blood mononuclear cells

By means of a selective DNA amplification technique called polymerase chain reaction, proviral sequences of the human immunodeficiency virus (HIV-1) were identified directly in DNA isolated from peripheral blood mononuclear cells (PBMCs) of persons seropositive but not in DNA isolated from PBMCs of persons seronegative for the virus. Primer pairs from multiple regions of the HIV-1 genome were used to achieve maximum sensitivity of provirus detection. HIV-1 sequences were detected in 100% of DNA specimens from seropositive, homosexual men from whom the virus was isolated by coculture, but in none of the DNA specimens from a control group of seronegative, virus culture-negative persons. However, HIV-1 sequences were detected in 64% of DNA specimens from seropositive, virus culture-negative homosexual men. This method of DNA amplification made it possible to obtain results within 3 days, whereas virus isolation takes up to 3 to 4 weeks. The method may therefore be used to complement or replace virus isolation as a routine means of determining HIV-1 infection.

Comparison of antigen assay and reverse transcriptase assay for detecting human immunodeficiency virus in culture

We compared an antigen capture assay (Abbott Laboratories, North Chicago, Ill.) with a reverse transcriptase assay to identify and quantify human immunodeficiency virus (HIV) in culture. In direct comparisons of serial dilutions of lymphadenopathy-associated virus type 1, the antigen assay was 100-fold more sensitive than the reverse transcriptase assay in detecting the virus. The antigen assay reacted strongly with 60 different HIV isolates but did not cross-react with human T-cell lymphotropic virus type I, human T-cell lymphotropic virus type II, cytomegalovirus, varicella-zoster virus, herpes simplex virus type 1, Epstein-Barr virus, adenovirus type 5, or poliovirus type 1 or with extracts from four different control human cell lines and eight different phytohemagglutinin-stimulated normal human lymphocytes. Peripheral blood lymphocyte samples from 50 individuals were evaluated by both the antigen assay and the reverse transcriptase assay. The cells from the 34 seropositive individuals were all positive by the antigen assay (range, 3 to 9 days; average time, 5.9 days) and the reverse transcriptase assay (range, 7 to 16 days; average time, 9.6 days). Cells from the 16 seronegative individuals were negative by both assays. These results indicate that the antigen assay is an important addition to the monitoring of HIV production in the lymphocytes of infected patients.

Virologic studies of HTLV-III/LAV in pregnancy: case report of a woman with AIDS

The number of cases of acquired immunodeficiency syndrome (AIDS) in women is increasing. As of December 30, 1985, 1075 cases in women had been reported to the Centers for Disease Control; 81% of these cases occurred in women of childbearing age (15 to 45 years). The human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) can be transmitted from mothers to their infants. Described is a woman with transfusion-acquired AIDS who was six weeks' pregnant at the time Pneumocystis carinii pneumonia was diagnosed. Despite the fact that HTLV III/LAV was isolated from her peripheral lymphocytes throughout pregnancy, transmission of the virus to her infant or husband does not appear to have occurred.

The safety of the hepatitis B vaccine. Inactivation of the AIDS virus during routine vaccine manufacture

In the United States, one hepatitis B vaccine (Heptavax-B) has been licensed for the prevention of hepatitis B virus infections. Even though this vaccine has been shown to be highly effective and well tolerated in controlled trials and has been recommended for use in those at risk for acquiring infection by hepatitis B virus, many individuals have been reluctant to be immunized for fear of contracting acquired immunodeficiency syndrome (AIDS). In this study, we demonstrate that each of the three inactivation steps used in the manufacture of Heptavax-B independently will inactivate the infectivity of high-titered preparations of the AIDS virus; recipients of the hepatitis B vaccine do not develop antibodies to the AIDS virus; the hepatitis B vaccine does not contain detectable levels of nucleic acids related to the AIDS virus. These observations clearly demonstrate that vaccination with the currently available hepatitis B vaccine poses no demonstrable risk for acquiring AIDS.

LAV/HTLV III presence in peripheral blood lymphocytes of seropositive young hemophiliacs

Recent studies indicate a high prevalence of seropositivity to the lymphadenopathy-associated virus/human T-lymphotropic virus (type III) among individuals with hemophilia exposed to clotting factor concentrates prepared from large donor pools. The peripheral blood lymphocytes of 19 young seropositive patients with inherited bleeding disorders were examined for the presence of this virus by coculture with phytohemagglutinin-stimulated lymphocytes. Viral isolates were obtained from six of 19 patients. While none of these patients have developed the acquired immunodeficiency syndrome (AIDS) or AIDS-related complex, five of them had lymphadenopathy in two noncontiguous areas, and two showed clinically symptomatic enlarged tonsils and adenoids. Of the 13 patients in whom virus was not demonstrated, five were judged clinically normal and five had mild lymphadenopathy in one anatomical area. These results suggest that as many as 33% of hemophiliacs (six of 19 patients studied), who have circulating antibodies to mature viral proteins, have viral-infected peripheral blood lymphocytes capable of infecting other lymphocytes in vitro.