What's new in genitourinary pathology 2023: WHO 5th edition updates for urinary tract, prostate, testis, and penis

The 5th edition WHO Classification of Urinary and Male Genital Tumours (2022) introduced many significant changes relevant to urologic daily practice, mainly to renal tumors which was covered in the What's New newsletter in September 2022. In this newsletter, we summarize the notable changes to bladder, prostate, testis, and penis based on the 5th edition of the WHO.

Adenoid cystic carcinoma metastatic to the kidney: a series of 10 patients emphasizing unilateral presentation and long time interval from primary diagnosis

Adenoid cystic carcinoma (AdCC) metastasis to kidney is rare. We identified 10 patients with metastatic AdCC in multi-institutional collaboration. Core needle biopsy was the most common specimen (n = 6). Patients were predominately female (n = 7) with a median age of 48 years (35-62 years). The most common primary location of the AdCC was head and neck (n = 6, among them parotid gland = 4), followed by lung (n = 2), breast (n = 1), and vulva (n = 1). Median lapse between primary AdCC and renal metastasis was almost 13 years (154 months, range 1-336 months). Moreover, all but one patient had unilateral kidney metastasis. The majority of metastatic AdCC within the kidney demonstrated mixed growth patterns, frequently cribriform, and tubular morphology. Follow-up available for 8 patients showed 6 alive with disease and 2 died of disease (the longest survival was 4 years past the diagnosis of renal metastasis). A systematic literature review including 29 patients revealed that kidney metastasis by AdCC is usually a late event, is typically unilateral, and is usually composed of one to three foci, and thus has clinical features which mimic a primary renal tumor.

Renal Pelvic Urothelial Carcinoma With Invasion Into Renal Medulla Can Be Redefined as pT2 to Improve Correlation With Survival

According to the American Joint Cancer Committee, pT3 renal pelvic carcinoma is defined as tumor invading the renal parenchyma and/or peripelvic fat and is the largest pT category, with notable survival heterogeneity. Anatomical landmarks within the renal pelvis can be difficult to discern. Using glomeruli as a boundary to differentiate renal medulla invasion from renal cortex invasion, this study aimed to compare patient survival of pT3 renal pelvic urothelial carcinoma on the basis of the extent of renal parenchyma invasion and, thereafter, determine whether redefining pT2 and pT3 improves pT correlation with survival. Cases with primary renal pelvic urothelial carcinoma were identified through a review of pathology reports from nephroureterectomies completed at our institution from 2010 to 2019 (n = 145). Tumors were stratified by pT, pN, lymphovascular invasion, and invasion of the renal medulla versus invasion of the renal cortex and/or peripelvic fat. Overall survival between groups was compared using Kaplan-Meier survival models and Cox regression multivariate analysis. pT2 and pT3 tumors had similar 5-year overall survival, with multivariate analysis demonstrating an overlap between hazard ratios (HRs) for pT2 (HR, 2.20; 95% CI, 0.70-6.95) and pT3 (HR, 3.15; 95% CI, 1.63-6.09). pT3 tumors with peripelvic fat and/or renal cortex invasion had a 3.25-fold worse prognosis than pT3 tumors with renal medulla invasion alone. Furthermore, pT2 and pT3 tumors with only renal medulla invasion had similar overall survival, whereas pT3 tumors with peripelvic fat and/or renal cortex invasion had a worse prognosis (P = .00036). Reclassifying pT3 tumors with only renal medulla invasion as pT2 yielded greater separation between survival curves and HR. Thus, we recommend redefining pT2 renal pelvic carcinoma to include renal medulla invasion and restricting pT3 to peripelvic fat and/or renal cortex invasion to improve the prognostic accuracy of pT classification.

The Stratification of Positive Lymph Nodes into pN1 and pN2 for Upper Urinary Tract Carcinoma is not Prognostically Significant

The 3^rd-7^th edition of the American Joint Committee on Cancer had 3 categories for positive lymph nodes (pN1-3) in upper urinary tract carcinoma. The 8^th edition removed pN3, defining pN1 as one lymph node with tumor deposit ≤ 2 cm and pN2 as a node with tumor deposit > 2 cm or metastases in multiple nodes. The aim of this study was to assess if the current pN categories impact survival in renal pelvic and ureteral carcinoma. Nephroureterectomies performed at our institution for primary upper urinary tract carcinoma between 2010-2019 were reviewed. Lymphadenectomy was performed in 73.3% of cases (151/206, median 9 nodes). Eighty-one (53.6%) patients were deceased at last review [pN0, 53 (44.5%); pN1-2, 28 (87.5%)]. There was no difference in overall or recurrence free survival between pN1 and pN2 with 5-year overall survival (95% confidence interval) of pN0, 60.7% (52.0-70.8%); pN1, 15.4% (4.3-35.2%); and pN2, 21.1% (8.8-40.3%). The metastatic deposit size threshold of 2 cm, number of positive lymph nodes, as well as extranodal extension did not correlate with overall or recurrence free survival. As such, pN1 and pN2 were grouped together with a 5-year overall survival of 18.8% (9.12-28.6%). The current stratification of upper urinary tract carcinoma into pN1 and pN2 does not provide prognostic information, and both yield a stage IV classification, regardless of pT or pM category. Therefore, we recommend further simplification of pN classification into one category for regional lymph node metastasis, irrespective of lymph node deposit size or number of positive lymph nodes.

Testicular Germ-Cell Tumors with Spermatic Cord Involvement: A Retrospective International Multi-Institutional Experience

The 8th Edition of the American Joint Committee on Cancer (AJCC) Staging Manual designates discontinuous involvement of spermatic cord soft tissue by testicular germ cell tumors as a metastatic deposit. We conducted a retrospective international multi-institutional study to validate the current recommendations. Thirty-three (72%) nonseminomatous and 13 (28%) seminomatous testicular germ cell tumors were collected from 15 institutions in America, Europe, and Asia. Testicular tumor size ranged from 1.3 to 18.0 cm (mean: 6.1). Cases were classified as discontinuous involvement of spermatic cord soft tissue (n = 26), continuous cord involvement (n = 17), or cord lymphovascular invasion (n = 3). The mean follow-up was 39 months. Clinical stage for discontinuous involvement of spermatic cord soft-tissue patients was I (local disease) in 2/24 (8%), II (regional disease) in 6/24 (25%), and III (distant disease) in 16/24 (67%) cases; 16 (67%) patients presented with distant metastasis. Clinical stage for continuous cord involvement patients was I in 9/17 (53%), II in 4/17 (23%), and III in 4/17 (23%); 4 (23%) patients presented with distant metastasis. Disease progression was seen in 4 patients with discontinuous involvement of spermatic cord soft tissue and 5 with continuous cord-involvement (p = 0.699). When comparing discontinuous and continuous cord involvement, a significant difference was found in cord margin status (p = 0.044), spermatic cord tumor size (p = 0.016), lymph-node involvement (p = 0.037), distant metastasis (p = 0.010), individual clinical stage (p = 0.003), and nonadvanced vs. advanced disease (p = 0.003) at presentation. In multivariate analysis, after adjusting for age, histology, testicular tumor size, percent of embryonal carcinoma, lymphovascular invasion, and cord margin status, discontinuous involvement of spermatic cord soft tissue was significantly associated (p = 0.011) with advanced clinical stage at presentation. Our findings support the designation of metastatic disease for discontinuous involvement of spermatic cord soft tissue, as introduced by the 8th edition of the AJCC staging.

The 2019 Genitourinary Pathology Society (GUPS) White Paper on Contemporary Grading of Prostate Cancer

CONTEXT.—

Controversies and uncertainty persist in prostate cancer grading.

OBJECTIVE.—

To update grading recommendations.

DATA SOURCES.—

Critical review of the literature along with pathology and clinician surveys.

CONCLUSIONS.—

Percent Gleason pattern 4 (%GP4) is as follows: (1) report %GP4 in needle biopsy with Grade Groups (GrGp) 2 and 3, and in needle biopsy on other parts (jars) of lower grade in cases with at least 1 part showing Gleason score (GS) 4 + 4 = 8; and (2) report %GP4: less than 5% or less than 10% and 10% increments thereafter. Tertiary grade patterns are as follows: (1) replace "tertiary grade pattern" in radical prostatectomy (RP) with "minor tertiary pattern 5 (TP5)," and only use in RP with GrGp 2 or 3 with less than 5% Gleason pattern 5; and (2) minor TP5 is noted along with the GS, with the GrGp based on the GS. Global score and magnetic resonance imaging (MRI)-targeted biopsies are as follows: (1) when multiple undesignated cores are taken from a single MRI-targeted lesion, an overall grade for that lesion is given as if all the involved cores were one long core; and (2) if providing a global score, when different scores are found in the standard and the MRI-targeted biopsy, give a single global score (factoring both the systematic standard and the MRI-targeted positive cores). Grade Groups are as follows: (1) Grade Groups (GrGp) is the terminology adopted by major world organizations; and (2) retain GS 3 + 5 = 8 in GrGp 4. Cribriform carcinoma is as follows: (1) report the presence or absence of cribriform glands in biopsy and RP with Gleason pattern 4 carcinoma. Intraductal carcinoma (IDC-P) is as follows: (1) report IDC-P in biopsy and RP; (2) use criteria based on dense cribriform glands (>50% of the gland is composed of epithelium relative to luminal spaces) and/or solid nests and/or marked pleomorphism/necrosis; (3) it is not necessary to perform basal cell immunostains on biopsy and RP to identify IDC-P if the results would not change the overall (highest) GS/GrGp part per case; (4) do not include IDC-P in determining the final GS/GrGp on biopsy and/or RP; and (5) "atypical intraductal proliferation (AIP)" is preferred for an intraductal proliferation of prostatic secretory cells which shows a greater degree of architectural complexity and/or cytological atypia than typical high-grade prostatic intraepithelial neoplasia, yet falling short of the strict diagnostic threshold for IDC-P. Molecular testing is as follows: (1) Ki67 is not ready for routine clinical use; (2) additional studies of active surveillance cohorts are needed to establish the utility of PTEN in this setting; and (3) dedicated studies of RNA-based assays in active surveillance populations are needed to substantiate the utility of these expensive tests in this setting. Artificial intelligence and novel grading schema are as follows: (1) incorporating reactive stromal grade, percent GP4, minor tertiary GP5, and cribriform/intraductal carcinoma are not ready for adoption in current practice.

Diagnostic approach in TFE3-rearranged renal cell carcinoma: a multi-institutional international survey

Transcription factor E3-rearranged renal cell carcinoma (TFE3-RCC) has heterogenous morphologic and immunohistochemical (IHC) features.131 pathologists with genitourinary expertise were invited in an online survey containing 23 questions assessing their experience on TFE3-RCC diagnostic work-up.Fifty (38%) participants completed the survey. 46 of 50 participants reported multiple patterns, most commonly papillary pattern (almost always 9/46, 19.5%; frequently 29/46, 63%). Large epithelioid cells with abundant cytoplasm were the most encountered cytologic feature, with either clear (almost always 10/50, 20%; frequently 34/50, 68%) or eosinophilic (almost always 4/49, 8%; frequently 28/49, 57%) cytology. Strong (3+) or diffuse (>75% of tumour cells) nuclear TFE3 IHC expression was considered diagnostic by 13/46 (28%) and 12/47 (26%) participants, respectively. Main TFE3 IHC issues were the low specificity (16/42, 38%), unreliable staining performance (15/42, 36%) and background staining (12/42, 29%). Most preferred IHC assays other than TFE3, cathepsin K and pancytokeratin were melan A (44/50, 88%), HMB45 (43/50, 86%), carbonic anhydrase IX (41/50, 82%) and CK7 (32/50, 64%). Cut-off for positive TFE3 fluorescent in situ hybridisation (FISH) was preferably 10% (9/50, 18%), although significant variation in cut-off values was present. 23/48 (48%) participants required TFE3 FISH testing to confirm TFE3-RCC regardless of the histomorphologic and IHC assessment. 28/50 (56%) participants would request additional molecular studies other than FISH assay in selected cases, whereas 3/50 participants use additional molecular cases in all cases when TFE3-RCC is in the differential.Optimal diagnostic approach on TFE3-RCC is impacted by IHC and/or FISH assay preferences as well as their conflicting interpretation methods.

Discontinuous Involvement of Spermatic Cord Soft Tissue in Testicular Germ Cell Tumors: A Multi-Institution Experience

Introduction/Objective

In the 8th Edition AJCC Cancer Staging Manual, discontinuous involvement of spermatic cord soft tissue (DISC) by testicular germ cell tumors (GCT) is regarded as metastatic deposit (pM1), placing the patient in clinical prognostic stage group (CPSG) III. We conducted a multi-institution study to corroborate or refute the current recommendations. Methods: Thirty-eight cases of GCT with spermatic cord involvement were collected from 13 institutions in Europe, Phillipines and America. Clinical and pathologic data was obtained.

Results

Tumors included 28 (73%) non-seminomatous and 10 (26%) seminomatous GCTs. Mean testicular tumor size was 6.6 cm (range 1.3-18). After review by an uropathologist, cases were classified as cord LVI [T2] (n=3), continuous cord involvement (CCI) [T3] (n=13), and DISC (n=22). Mean cord tumor size for DISC was 0.9 cm (range 0.1-4.5).

CPSG was available for 33 and follow-up (FU) for22 patients with a mean length of FU of 38 months (range 2-144). Seven (39%) DISC patients were CPSG II (regional LN metastases), and 11 (61%) CPSG III (distant metastases). On FU, 5 (45%) DISC patients had no evidence of disease (NED); 6 (55%) were alive with disease (AWD). Three (25%)

CCI patients were CPSG I (local disease), 6 (50%) CPSG II, and 3 (25%) CPSG III. On FU, 6 (60%) CCI patients were NED, 4 (40%) AWD. Cord LVI patients were one in each CPSG. One cord LVI patient was NED, the others were lost at FU. All DISC (100%) patients with available CPSG had advanced disease (CPSG II or III), compared to 75% of CCI, and 67% of cord LVI patients.

Conclusion

Although it did not reach statistical significance (p=0.054; Fisher’s exact test), DISC patients were more likely to have CPSG II and III compared to CCI patients. Our findings suggest a worse behavior in patients with DISC, supporting a higher pathologic stage than CCI.

Practice patterns related to prostate cancer grading: results of a 2019 Genitourinary Pathology Society clinician survey

PURPOSE

To survey urologic clinicians regarding interpretation of and practice patterns in relation to emerging aspects of prostate cancer grading, including quantification of high-grade disease, cribriform/intraductal carcinoma, and impact of magnetic resonance imaging-targeted needle biopsy.

MATERIALS AND METHODS

The Genitourinary Pathology Society distributed a survey to urology and urologic oncology-focused societies and hospital departments. Eight hundred and thirty four responses were collected and analyzed using descriptive statistics.

RESULTS

Eighty percent of survey participants use quantity of Gleason pattern 4 on needle biopsy for clinical decisions, less frequently with higher Grade Groups. Fifty percent interpret "tertiary" grade as a minor/<5% component. Seventy percent of respondents would prefer per core grading as well as a global/overall score per set of biopsies, but 70% would consider highest Gleason score in any single core as the grade for management. Seventy five percent utilize Grade Group terminology in patient discussions. For 45%, cribriform pattern would affect management, while for 70% the presence of intraductal carcinoma would preclude active surveillance.

CONCLUSION

This survey of practice patterns in relationship to prostate cancer grading highlights similarities and differences between contemporary pathology reporting and its clinical application. As utilization of Gleason pattern 4 quantification, minor tertiary pattern, cribriform/intraductal carcinoma, and the incorporation of magnetic resonance imaging-based strategies evolve, these findings may serve as a basis for more nuanced communication and guide research efforts involving pathologists and clinicians.

NCL Inhibition Exerts Antineoplastic Effects against Prostate Cancer Cells by Modulating Oncogenic MicroRNAs

Prostate cancer (PCa) is the most frequently diagnosed cancer in men and second most common cause of cancer-related deaths in the United States. Androgen deprivation therapy (ADT) is only temporarily effective for advanced-stage PCa, as the disease inevitably progresses to castration-resistant prostate cancer (CRPC). The protein nucleolin (NCL) is overexpressed in several types of human tumors where it is also mislocalized to the cell surface. We previously reported the identification of a single-chain fragment variable (scFv) immuno-agent that is able to bind NCL on the surface of breast cancer cells and inhibit proliferation both in vitro and in vivo. In the present study, we evaluated whether NCL could be a valid therapeutic target for PCa, utilizing DU145, PC3 (CRPC), and LNCaP (androgen-sensitive) cell lines. First, we interrogated the publicly available databases and noted that higher NCL mRNA levels are associated with higher Gleason Scores as well as with recurrent and metastatic tumors. Then, using our anti-NCL scFv, we demonstrated that NCL is expressed on the surface of all three tested cell lines and that NCL inhibition results in reduced proliferation and migration. We also measured the inhibitory effect of NCL targeting on the biogenesis of oncogenic microRNAs such as miR-21, -221 and -222, which was cell context dependent. Taken together, our data provide evidence that NCL targeting inhibits the key hallmarks of malignancy in PCa cells and may provide a novel therapeutic option for patients with advanced-stage PCa.

Clinicopathologic analysis of renal cell carcinoma containing Intratumoral fat with and without osseous metaplasia

BACKGROUND

There is minimal information regarding the prevalence of intratumoral adipose in renal cell carcinoma (RCC), and no study has assessed the impact of intratumoral adipose on the preoperative imaging diagnosis. The aim of this study was to investigate the prevalence and histopathologic characteristics of entrapped adipose with or without osseous metaplasia in RCC nephrectomy specimens and to determine if this finding impacted the preoperative imaging interpretation.

METHODS

704 RCC specimens were prospectively evaluated for entrapped adipose and osseous metaplasia (423 partial nephrectomies, 281 total nephrectomies; 327 pT1a, 377 ≥ pT1b; 510 clear cell, 119 papillary, 30 chromophobe, 22 clear cell papillary, 23 other). Imaging reports were obtained, and the presence of intratumoral fat or calcification and the radiologic diagnostic impression were recorded.

RESULTS

3% (n = 21) contained microscopically identified intratumoral adipose, with a similar frequency in the main histologic subtypes (p = 0.76). Mean metaplastic deposit size was 0.4 cm, mean deposit to capsule distance 0.2 cm, and 29% involved the tumor capsule. Histologically identified adipose was infrequently noted via imaging (13%), and only 1 case with histologically identified metaplasia had a radiologic diagnostic differential of angiomyolipoma (1/704, 0.1%).

CONCLUSION

While intratumoral adipose and/or osseous metaplasia can be observed within RCC, it is extremely rare for the radiologic diagnostic impression to have been confounded by histologically identified entrapped adipose. Awareness that metaplastic deposits are usually near the tumor capsule and may be minute could help prevent errors in diagnosis or staging.

Does the addition of AMACR to CK20 help to diagnose challenging cases of urothelial carcinoma in situ?

Background

Urothelial carcinoma in situ (CIS) in the bladder can be difficult to diagnose due to factors including procedural artifact, minimal tissue sampled, therapy-related changes, and various CIS growth patterns. Prior data has demonstrated an increase in alpha-methylacyl-CoA-racemase (AMACR) in urothelial CIS, but there is no information on its utility for diagnosing difficult cases. The aim of this investigation was to assess the expression of AMACR that was ordered on equivocal bladder cases during clinical practice.

Methods

Transurethral resections of the bladder in which AMACR and CK20 were performed during diagnostic workup were identified and cases with a final diagnosis of CIS (n = 22) or non-neoplastic urothelium (n = 30) were selected. Additionally, cases in which a diagnosis of CIS was rendered without IHC (n = 20) were selected and tested for AMACR expression.

Results

Sensitivity of AMACR for CIS diagnosed with IHC during clinical practice was 73% and specificity was 97%, while CK20 was 95% sensitive and 80% specific. Sensitivity of AMACR in CIS diagnosed without IHC was 100%. In all groups, AMACR had inconsistent intensity, compared to CK20 which had consistent, strong intensity.

Conclusions

AMACR was usually positive in urothelial CIS and negative in non-neoplastic urothelium. However, it is important to note that AMACR was less sensitive in difficult cases, while CK20 was more sensitive with more consistent, strong staining compared to AMACR.

Diagnostic terminology used to describe atypia on breast core needle biopsy: correlation with excision and upgrade rates

Background

Subjective qualitative descriptors are sometimes used to describe atypical breast lesions diagnosed on core needle biopsy (CNB) which are limited in extent. In clinical practice, this terminology is used to imply a lower expected risk of upgrade on surgical excision (EXC). It is uncertain how subjective terminology impacts clinical management.

Methods

We conducted a retrospective review of CNB with atypia and compared the EXC and upgrade rates of atypical ductal hyperplasia (ADH) and flat epithelial atypia (FEA) to lesions described as “focal” atypical ductal hyperplasia (FADH), to determine the impact of this diagnostic phrasing on surgical management and risk of malignancy.

Results

FADH and ADH were excised at similar rates (82% vs. 78%). FADH lesions showed a similar upgrade rate (13%) compared to non-focal ADH (10%), and both showed a trend towards higher upgrade and EXC rates compared to FEA. ADH, FADH and FEA all had an upgrade risk that warranted EXC. In non-upgraded EXC, for each diagnostic category we observed similar rates of residual atypia in the EXC.

Conclusions

Pathologists should avoid the use of qualitative descriptors when describing ADH on CNB because of the potential of this terminology to influence clinical decision making which is unwarranted.

Impact of the 2018 ASCO/CAP HER2 Guideline Focused Update

OBJECTIVES

The 2018 American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) human epidermal growth factor receptor 2 (HER2) guideline focused update revises the HER2 scoring criteria. We evaluated the impact on HER2 rates in breast carcinoma diagnosed at our center.

METHODS

In a retrospective series of breast core biopsies with invasive carcinoma diagnosed between 2014 and 2017 (n = 1,350), HER2 status was classified according to 2013 and 2018 ASCO/CAP guidelines and changes in HER2 status identified.

RESULTS

The 2018 guidelines reclassified the HER2 status of 6% of patients. Most changed from HER2 equivocal status (equivocal by immunohistochemistry and fluorescence in situ hybridization under the 2013 guidelines) to HER2-negative status (2018 guidelines). The HER2-positive rate decreased by 0.4%.

CONCLUSIONS

The 2018 guidelines decrease the rate of HER2 equivocal and positive breast cancer and reduce repeat HER2 testing on excision specimens. Approximately 0.4% of patients will become newly ineligible for anti-HER2 therapy.

A combination of GATA3 and SOX10 is useful for the diagnosis of metastatic triple-negative breast cancer

In metastatic breast cancer (MBC), it can be difficult to establish the origin if the primary tumor is triple negative or if there is a loss of biomarker expression. SOX10 expression has been reported in primary triple-negative breast cancer but is poorly studied in metastatic lesions. In this study, the diagnostic utility of a panel of SOX10, GATA3, and androgen receptor (AR) in MBC negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 was evaluated and compared with the expression of these markers in the matched primary breast cancer. In a series of 57 triple-negative MBCs, 82% were positive for GATA3, 58% for SOX10, and 25% for AR. Nearly all MBCs (95%) were positive for either GATA3 or SOX10, with 46% dual positive and 5% of cases negative for both markers. Most GATA3-negative MBC cases were SOX10 positive (70%). AR expression was only seen in GATA3-positive MBC (25%) and was significantly more frequent in SOX10-negative MBC (48%) versus SOX10-positive MBC (9%; P = .001). Concordance for GATA3, SOX10, and AR between the primary and metastasis was 89%, 88%, and 80%, respectively. Although GATA3 is a more sensitive lineage marker than SOX10 in MBC, SOX10 is a useful adjunct because it is positive in most GATA3-negative breast metastases. Using both GATA3 and SOX10 is recommended for confirming breast as the site of origin in metastases that lack estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 expression, whereas the addition of AR is not helpful.

HER2 equivocal breast cancer that is positive by alternative probe HER2 FISH are classified as HER2 negative by Oncotype DX

In breast cancer, human epidermal growth factor receptor 2 (HER2) status is determined by immunohistochemistry (IHC) and/or in situ hybridization. Oncotype DX also reports HER2 status by an rt-PCR-based assay. Assay concordance between IHC and fluorescent in situ hybridization (FISH) (including alternative probe HER2 FISH) vs Oncotype DX HER2 rt-PCR has not been described in the post-2013 American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) HER2 Guideline revision setting. We performed a retrospective review of HER2 equivocal invasive breast carcinoma from 2014 to 2016 with the Oncotype DX HER2 result. Fifteen patients with HER2 equivocal invasive breast cancer had Oncotype DX performed. Of these, 13 underwent alternative probe HER2 FISH yielding 4 negative, 6 equivocal and 3 positive results. All 15 cases were classified as HER2 negative by Oncotype DX rt-PCR, including the three cases which were positive by alternative probe HER2 FISH, yielding a discordance rate for Oncotype DX rt-PCR HER2 of 20% (3/15). All three patients with HER2-positive breast cancer on the basis of alternative probe HER2 FISH received anti-HER2-targeted therapy. Treatment decisions based on HER2 status should utilize the IHC/FISH result as Oncotype DX results may incorrectly disqualify some patients from being eligible for anti-HER2 therapy based on the current 2013 ASCO/CAP HER2 Guidelines.

Impact of the Pathologist on Prostate Biopsy Diagnosis and Immunohistochemical Stain Usage Within a Single Institution

OBJECTIVES

To determine whether pathologists in a tertiary care institution vary in diagnosis and immunohistochemical stain usage in prostate biopsy specimens.

METHODS

Men who underwent prostate needle biopsies between 2008 and 2013 were included.

RESULTS

In total, 1,777 prostate biopsy specimens diagnosed by nine pathologists showed variation in diagnostic reporting (atypical small acinar proliferation, 2.0%-8.0%; high-grade prostatic intraepithelial neoplasia, 2.0%-8.5%; nonneoplastic, 30.2%-48.3%; adenocarcinoma, 46.2%-55.3%; P < .001). Variation in Gleason scoring was observed (P < .001), with the 4 + 3 = 7 category having the greatest variability (6.9%-30.3%). A blinded review from the most outlying pathologist in this category revealed 45% grading discrepancies. The mean number of immunostains performed per case (0.3-1.2) differed between pathologists (P < .001), and one pathologist used immunostains at twice the rate of the remaining cohort.

CONCLUSIONS

Case pathologist significantly affects prostate biopsy diagnosis and immunohistochemical workup. We recommend evaluation for outlying practice patterns to provide consistent and efficient patient care.

Minimal Clinical Impact of Intraoperative Examination of Sentinel Lymph Nodes in Patients With Ductal Carcinoma In Situ: An Opportunity for Improved Resource Utilization

OBJECTIVES

There is little information regarding sentinel lymph node (SLN) frozen-section examination in patients with a history of ductal carcinoma in situ (DCIS). We evaluated the usage, clinical impact, and pathology resources used for SLN cryosectioning in mastectomy cases with a DCIS history.

METHODS

Mastectomies with SLNs submitted from 2012 to 2013 at a tertiary care center were analyzed. Medicare reimbursement was used to estimate pathology health care expenditures of intraoperative frozen sections.

RESULTS

There was no difference in the rate of SLN frozen-section examination or parts submitted, total blocks frozen, total blocks submitted, or total SLNs identified per case between the DCIS (n = 139) and invasive (n = 369) groups. Nine patients with DCIS had SLN metastases (three macrometastases, two micrometastases, and four isolated tumor cells), all of which were examined by frozen section. Only the macrometastases were identified by cryosectioning, which led to two synchronous axillary lymph node dissections that did not yield any additional positive nodes. A total of $19,313 was spent for pathology per DCIS patient with surgical management affected, whereas only $1,019 was spent per invasive carcinoma patient affected.

CONCLUSIONS

Decreasing SLN frozen-section use in patients with a history of DCIS represents an opportunity for pathology cost containment.

Quantitative Assessment of Heterogeneity in Bladder Tumor MRI Diffusivity: Can Response be Predicted Prior to Neoadjuvant Chemotherapy?

Background:

It is a critical unmet need to predict chemosensitivity in muscle-invasive bladder cancer patients who receive neoadjuvant chemotherapy (NAC). Quantification of tumor heterogeneity has been shown to be useful in the assessment of therapeutic response. Apparent diffusion coefficient (ADC) is derived from diffusion weighted MRI (DWI) to quantify the water diffusivity which characterizes micro-cellularity in tumor tissues.

Objective:

The aim of this study is to assess if a quantitative measurement of ADC heterogeneity in bladder tumors can be a predictor of therapeutic response to NAC.

Materials and Methods:

Twenty patients with pT2 bladder cancer have been included in this study. Patient MRI was performed on a 3T system with DWI prior to NAC. Regions of interest (ROIs) were placed over the whole tumor volume on ADC maps to acquire a data matrix of voxel-wise ADC values for each patient. We performed histogram analysis on each ADC data matrix to calculate uniformity (U) and entropy (E). These quantities were subsequently correlated with the patient’s response to chemotherapy. Statistical significance was found with P < 0.05.

Results:

Fifteen patients were categorized as responders, and five as non-responders. The data showed that tumors of responders were significantly higher in U (P = 0.01) and lower in E (P < 0.01) than non-responders. This finding indicates that resistant tumors were more heterogeneous in their spatial distribution of ADC values. While this difference in ADC heterogeneity was not always visually recognizable, it could be quantified by the data analytics.

Conclusions:

This study demonstrates that the quantitative readout of tumor heterogeneity in micro-cellularity is associated with the patient’s defined response to chemotherapy. Quantification of tumor ADC heterogeneity may provide useful information to enable the prediction of chemotherapeutic response prior to the treatment to improve patient outcomes.

von Brunn's Nests and Follicular Cystitis Following Intradetrusor OnabotulinumtoxinA Injections for Overactive Bladder

A 67-year-old female with refractory OAB was treated with intradetrusor Botox. She subsequently developed multiple papillary bladder lesions with tissue biopsy showing Von Brunn's nests. Von Brunn’s nests are benign bladder lesions similar in appearance to a rare urothelial tumor called Nested Variant of Urothelial Carcinoma (NVUC). It is critical that patients with these findings undergo evaluation to rule out the presence of carcinoma. This finding suggests the possibility of a previously unreported adverse reaction in association with intradetrusor Botox.

Comparison of Oncotype DX With Modified Magee Equation Recurrence Scores in Low-Grade Invasive Carcinoma of Breast

OBJECTIVES

Several specific histologic types of invasive carcinoma of breast, including invasive tubular carcinoma (ITC), invasive mucinous carcinoma (IMC), and classical invasive lobular carcinoma (CILC), are considered low-grade carcinomas with favorable outcomes. We aimed to investigate the utility of Oncotype DX test in these tumors by comparing its recurrence score (RS) with the modified Magee equation RS.

METHODS

Oncotype DX RSs were collected and modified Magee equation RSs were calculated in 163 low-grade invasive breast carcinomas, including 105 CILCs, 41 ITCs, and 17 IMCs.

RESULTS

In total, 105 (64.4%) cases had an Oncotype DX RS less than 18, 56 (34.4%) were between 18 and 30, and two (1.2%) were more than 30. Of the cases, 124 (76.1%) had a modified Magee RS less than 18, 39 (23.9%) were between 18 and 30, and no case was more than 30. The overall agreement between Oncotype DX RS and modified Magee RS risk categories was 68.7%. Two CILCs with an Oncotype DX RS more than 30 had modified Magee equation RSs of 20.3 and 20.0, respectively, and both had not shown recurrent disease.

CONCLUSIONS

Performing Oncotype DX on low-grade invasive carcinomas is unlikely to provide additional useful information beyond Magee equation RS, and eliminating Oncotype DX from these cases could lead to substantial cost savings.

Using the Modified Magee Equation to Identify Patients Unlikely to Benefit From the 21-Gene Recurrence Score Assay (Oncotype DX Assay)

OBJECTIVES

This study aimed to compare a modified Magee equation with Oncotype DX (Genomic Health, Redwood City, CA) recurrence score (RS) and identify patients who are unlikely to benefit from Oncotype DX.

METHODS

Magee equation RS was calculated in 438 cases and correlated with Oncotype DX RS.

RESULTS

The Pearson correlation coefficient ( r ) for the Magee equation and Oncotype DX RS was 0.6645 ( P  < .00001), and the overall agreement was 66.4%. All cases (11.6%) with a Magee equation RS greater than 30 or 11 or less had been correctly predicted to have either high Oncotype DX RS or low Oncotype DX RS, respectively.

CONCLUSIONS

The modified Magee equation is able to identify up to 12% patients who are unlikely to benefit from Oncotype DX testing. Using the modified Magee equation RS on these patients would be an alternative to Oncotype DX, leading to cost savings.

Does the gross prosector impact pT3 subclassification or lymph node counts in bladder cancer?

Gross prosector analysis of perivesicular adipose tumor invasion is the sole differentiator between pT3 substages, and gross evaluation is critical to lymph node identification. Gross prosector impact on pT3 subclassification and lymph node counts in cystectomy specimens resected for bladder cancer has not been previously analyzed. Both pT3 subclassification and total number of lymph nodes removed at radical cystectomy for bladder cancer are considered important components of the pathology report; however, both have controversial prognostic significance. Our objective was to assess the impact of the gross prosector on pT3 substaging and lymph node count. Pathology reports from 560 cystectomy cases performed for primary bladder cancer were reviewed. Educational interventions regarding cystectomy gross prosector documentation were conducted. Gross prosectors did not document the presence or absence of macroscopic perivesicular adipose invasion in 17% of cases. There was a decrease in the frequency of cases lacking documentation after educational intervention (33% to 5%, P<.01). Most pT3 cases lacking documentation were classified as pT3a (75%). The percentage of pT3 cases classified as pT3a decreased after intervention (68% to 35%, P<.01). Overcounting of lymph nodes by gross prosectors was more common than undercounting (22% versus 2%). Pathology residents and prosectors with lower caseloads had more uncounted lymph packets (P<.01). In conclusion, we demonstrated an impact of the gross prosector on pT3 substaging and lymph node counts within bladder cancer resection specimens. This novel variable may confound the relationship of these parameters upon oncologic outcomes and should be incorporated into quality assurance programs.

Visually Meaningful Histopathological Features for Automatic Grading of Prostate Cancer

Histopathologic features, particularly Gleason grading system, have contributed significantly to the diagnosis, treatment, and prognosis of prostate cancer for decades. However, prostate cancer demonstrates enormous heterogeneity in biological behavior, thus establishing improved prognostic and predictive markers is particularly important to personalize therapy of men with clinically localized and newly diagnosed malignancy. Many automated grading systems have been developed for Gleason grading but acceptance in the medical community has been lacking due to poor interpretability. To overcome this problem, we developed a set of visually meaningful features to differentiate between low- and high-grade prostate cancer. The visually meaningful feature set consists of luminal and architectural features. For luminal features, we compute: 1) the shortest path from the nuclei to their closest luminal spaces; 2) ratio of the epithelial nuclei to the total number of nuclei. A nucleus is considered an epithelial nucleus if the shortest path between it and the luminal space does not contain any other nucleus; 3) average shortest distance of all nuclei to their closest luminal spaces. For architectural features, we compute directional changes in stroma and nuclei using directional filter banks. These features are utilized to create two subspaces; one for prostate images histopathologically assessed as low grade and the other for high grade. The grade associated with a subspace, which results in the minimum reconstruction error is considered as the prediction for the test image. For training, we utilized 43 regions of interest (ROI) images, which were extracted from 25 prostate whole slide images of The Cancer Genome Atlas (TCGA) database. For testing, we utilized an independent dataset of 88 ROIs extracted from 30 prostate whole slide images. The method resulted in 93.0% and 97.6% training and testing accuracies, respectively, for the spectrum of cases considered. The application of visually meaningful features provided promising levels of accuracy and consistency for grading prostate cancer.

Perinephric Hematoma and Hemorrhagic Shock as a Rare Presentation for an Acutely Obstructive Ureteral Stone with Forniceal Rupture: A Case Report

Background: Spontaneous perinephric hematoma (SPH) secondary to a forniceal rupture as the first presenting sign for an obstructive ureteral stone in a patient without history of urolithiasis has not been described previously.

Case presentation: We report a 70-year-old Caucasian male patient who presented to our emergency room with fever, altered mental status, and left flank pain. He had a temperature of 103.3°F, tachycardia, but stable blood pressure. He had left flank tenderness. A computed tomography scan of the abdomen/pelvis with intravenous contrast revealed an intracapsular hematoma (13.3 × 10.0 × 6.4 cm) with an active bleeding and a 1.1 cm left proximal ureteral stone. The patient became quickly hemodynamically unstable and was taken for emergent exploratory laparotomy and left nephrectomy. An active bleeding was encountered secondary to a (2.4 × 2.0 cm) lateral capsular defect in the kidney.

Conclusion: Hemorrhagic/septic shock as a presenting sign for an obstructive ureteral stone may require an emergent nephrectomy in a hemodynamically unstable patient.

Do Histopathologic Variables Affect the Reporting of Lymphovascular Invasion in Testicular Germ Cell Tumors?

OBJECTIVES

Identification of lymphovascular invasion (LVI) in testicular germ cell tumors (GCTs) is a challenging yet important aspect of cancer staging that can alter therapeutic management. Our study aimed to identify pathologic features that affect the reporting of LVI.

METHODS

Pathology report and slide review of orchiectomies performed at our institution between 2007 and 2013 for testicular GCTs were performed.

RESULTS

Seminomas grossed by residents had a higher rate of reported LVI compared with specimens grossed by pathology assistants (46% vs 15%). Tumor displacement artifact was more frequent in seminomas vs mixed GCTs (60% vs 38%). LVI concordance was high upon review (κ = 0.77), with displacement artifact present in all discrepancies. Tumor emboli from cases reported to have LVI had a higher frequency of tumor cohesiveness, smooth contours, and adherence to vessel walls compared with tumor emboli that were considered pseudo-LVI. Presence of fibrin and RBCs were features found at a similar frequency in emboli that were reported as LVI compared with those deemed artifactual.

CONCLUSIONS

Grosser type, tumor subtype, tumor displacement artifact, and characteristics of tumor emboli are pathologic features that affect the interpretation of LVI in testicular GCTs. Pathologists should be aware of these variables to more accurately diagnose LVI.

Urologist's Impact on Needle Core Prostate Biopsy Histopathologic Variables Within a Single Institution

OBJECTIVE

To assess the urologist's impact on prostate needle core biopsy variables including number of containers submitted, total core length, longest core length, and individual core length threshold values, and to elucidate the relationship between these variables and cancer detection rate within a recent cohort.

METHODS

A retrospective search was performed to identify patients who had an extended transrectal ultrasound-guided prostate needle core biopsy between 2008 and 2013.

RESULTS

One thousand one prostate biopsies were analyzed. Total core length (mean 13.2-22.9 cm, P < .001) significantly varied by submitting urologist but did not impact cancer detection rate per case. Increased core length per container impacted the cancer detection per container (P < .001). The number of cores that met threshold values of 0.5, 1.0, and 1.5 cm as well as longest individual core length (mean 1.7-2.2 cm) significantly varied between urologist (P < .001), although there was no association between these variables and cancer detection. Container number differed significantly between urologists (P < .001) but did not correlate with cancer detection. For the single urologist with a change in his submission protocol during the study period, a nonsignificant change in cancer detection was noted when comparing 12-14 containers vs 6-9 containers.

CONCLUSION

Submitting urologist significantly impacts prostate biopsy metrics. An increased amount of tissue per container was associated with higher rates of cancer per container. A nonsignificant change in cancer detection rate was observed when container number was reduced from 12-14 to 6-9.

Does the Renal Parenchyma Adjacent to the Tumor Contribute to Kidney Function? A Critical Analysis of Glomerular Viability in Partial Nephrectomy Specimens

OBJECTIVE

To evaluate the viability of glomeruli in the peritumor parenchyma of partial nephrectomy specimens removed for renal cell carcinoma (RCC) and relate it to kidney function, to better understand the contribution of peritumor parenchyma to renal function.

MATERIALS AND METHODS

A retrospective analysis of 53 partial nephrectomies containing RCC was performed. Glomeruli within 0.25-cm increments from the tumor were quantified and histologically assessed for viability. Tumor size, minimum and maximum margin size, and pre- and postoperative estimated glomerular filtration rate (eGFR) were obtained.

RESULTS

Glomerular viability positively correlated with distance from tumor with mean viable glomeruli in successive 0.25-cm increments of 0-0.25 cm, 58%; 0.25-0.5 cm, 80%; 0.5-0.75 cm, 90%; and 0.75-1.0 cm, 92%. Glomerular viability near the tumor did not correlate with preoperative eGFR, whereas decreased viability further from the tumor did correlate with worse preoperative eGFR. Tumor size showed a nonstatistically significant positive trend with minimum (median 0.15 cm) and maximum margin (median 0.7 cm) sizes. Percent change of glomerular filtration rate did not correlate with margin size (P = .190).

CONCLUSION

Renal parenchyma immediately adjacent to RCC contains fewer viable glomeruli compared with the parenchyma further from the tumor. Based on this information, attempts to preserve all non-neoplastic renal parenchyma via a surgical margin approaching zero may not necessarily result in clinically relevant differences in the amount of viable glomeruli remaining or the renal function preserved.

Concordance of lymphovascular invasion diagnosed in penile carcinoma with and without the immunohistochemical markers ERG and CD31

Lymphovascular invasion (LVI) is an independent predictor of metastatic lymph node disease in penile carcinoma and is one factor used to guide clinical management. The presence of LVI with and without the use of the endothelial immunohistochemical (IHC) markers, ERG and CD31, was retrospectively assessed in 46 penectomy cases containing invasive penile carcinoma (43 squamous cell carcinoma and 3 non-squamous cell carcinoma). Concordance for the detection of LVI between the original report, upon pathology review, and with the use of IHC was determined and histologic pitfalls were identified. For penile squamous cell carcinoma, LVI was diagnosed in 27.9% of tumors in the original reports, 16.3% upon pathology review, and in 16.3% with use of ERG and CD31. Concordance of LVI identification in the original report compared to IHC was 74.4% while concordance of review compared to IHC was 95.3%. Using IHC data as the reference, false positive LVI diagnoses were more common in the original report than false negatives. Histologic mimickers of LVI including involvement of the penile corpora cavernosum or spongiosum vasculature, seromucinous colonization, and a nested pattern of tumor invasion were identified. We demonstrated that it was not uncommon for LVI in penile carcinoma to be overdiagnosed or underdiagnosed. The use of endothelial IHC markers, such as ERG or CD31, or additional pathology consultation is recommended for penectomy cases in which LVI is difficult to histologically discern.

Abstract 4312: A novel miRNA-based predictive model for biochemical failure following post-prostatectomy salvage radiation therapy

Prostate cancer (PCa) is the second most common cancer among men worldwide. Radical prostatectomy (RP) is a standard treatment for PCa, yet 30-40% of these men experience biochemical failure (BF) and must undergo additional treatment such as radiation therapy (RT). Unfortunately, a subset of these patients develop resistance to RT and have disease progression. It is important to stratify men based on risk of recurrence as well as identify the most suitable treatment approach to take in PCa to reduce non-necessary patient burden. Currently used methods that include clinical and histopathological factors lack disease specificity and sensitivity. A more informative classification system is needed and molecular biomarkers may serve to bridge the gap of the inadequacies of current prognostic and predictive methods. There were two major objectives for this study. The first was to identify microRNA (miRNA) signatures that predict time to BF post-RP. Secondly, and most novel to the field of RT, we sought to determine miRNAs that could predict BF following post-RP salvage RT as well as develop a new model using both miRNAs and clinical factors. Using the NanoString Human v2 array, we profiled 800 miRNAs in forty-three PCa patients that all experienced BF post-RP and subsequently underwent salvage RT. We identified an 88-miRNA signature that could predict time to BF post-RP using multivariate Cox regression analysis. We observed that these 88 miRNAs could classify patients into two groups (early vs late BF) and that the probabilities to the time to first BF were significantly different between the groups. To identify miRNAs that could independently predict BF post-salvage RT, we performed a multivariate Cox regression analysis with lymph node status and Gleason score which lead to the discovery of nine miRNAs. We wanted to not only identify miRNAs that could independently predict BF post-salvage RT, but also develop a model using these miRNAs in combination with currently used clinical factors to improve upon existing methods. We performed a Cox regression analysis including lymph node status, Gleason score, and the 9 independently identified miRNAs and applied a step-wise model selection strategy to determine the best predictive miRNAs. Two miRNAs with Gleason score and lymph node status had the best predictability. Further specificity and sensitivity analysis indicated that the addition of these miRNAs greatly improved the predictive ability of lymph node status and Gleason score alone (AUC = 0.83 vs 0.66). To the best of our knowledge, this is the first report correlating molecular biomarkers with response to salvage RT. This research has the potential to greatly impact future treatment strategies by using molecular biomarker profiles alone or in combination with other clinical factors to assign the most suitable therapy to individuals the first time and thus avoid over or under treatment.

Citation Format: Erica Hlavin Bell, Simon Kirste, Jessica L. Fleming, Petra Stegmaier, Vaness Drendel, Xiaokui Mo, Stella Ling, Denise Fabian, Isabel Manring, Cordula A. Jilg, Wolfgang Schultze-Seemann, Maureen McNulty, Debra L. Zynger, Douglas Martin, Julia White, Martin Werner, Anca L. Grosu, Arnab Chakravarti. A novel miRNA-based predictive model for biochemical failure following post-prostatectomy salvage radiation therapy. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4312. doi:10.1158/1538-7445.AM2015-4312

Chitosan-Decorated Doxorubicin-Encapsulated Nanoparticle Targets and Eliminates Tumor Reinitiating Cancer Stem-like Cells

Tumor reinitiating cancer stem-like cells are responsible for cancer recurrence associated with conventional chemotherapy. We developed a doxorubicin-encapsulated polymeric nanoparticle surface-decorated with chitosan that can specifically target the CD44 receptors of these cells. This nanoparticle system was engineered to release the doxorubicin in acidic environments, which occurs when the nanoparticles are localized in the acidic tumor microenvironment and when they are internalized and localized in the cellular endosomes/lysosomes. This nanoparticle design strategy increases the cytotoxicity of the doxorubicin by six times in comparison to the use of free doxorubicin for eliminating CD44(+) cancer stem-like cells residing in 3D mammary tumor spheroids (i.e., mammospheres). We further show these nanoparticles reduced the size of tumors in an orthotopic xenograft tumor model with no evident systemic toxicity. The development of nanoparticle system to target cancer stem-like cells with low systemic toxicity provides a new treatment arsenal for improving the survival of cancer patients.

Performance comparison of 1.5-T endorectal coil MRI with 3.0-T nonendorectal coil MRI in patients with prostate cancer

RATIONALE AND OBJECTIVES

To compare prostate morphology, image quality, and diagnostic performance of 1.5-T endorectal coil magnetic resonance (MR) imaging (MRI) and 3.0-T nonendorectal coil MRI in patients with prostate cancer.

MATERIALS AND METHODS

MR images obtained of 83 patients with prostate cancer using 1.5-T MRI systems with an endorectal coil were compared to images collected from 83 patients with a 3.0-T MRI system. Prostate diameters were measured, and image quality was evaluated by one American Board of Radiology (ABR)-certified radiologist (reader 1) and one ABR-certified diagnostic medical physicist (reader 2). The likelihood of the presence of peripheral zone cancer in each sextant and local extent was rated and compared to histopathologic findings.

RESULTS

Prostate anterior-posterior diameter measured by both readers was significantly shorter with 1.5-T endorectal MRI than with 3.0-T MRI. The overall image quality score difference was significant only for reader 1. Both readers found that the two MRI systems provided a similar diagnostic accuracy in cancer localization, extraprostatic extension, and seminal vesicle involvement.

CONCLUSIONS

Nonendorectal coil 3.0-T MRI provides prostate images that are natural in shape and that have comparable image quality to those obtained at 1.5 T with an endorectal coil, but not superior diagnostic performance. These findings suggest an opportunity exists for improving technical aspects of the 3.0-T prostate MRI.

Agonist and antagonist switch DNA motifs recognized by human androgen receptor in prostate cancer

Human transcription factors recognize specific DNA sequence motifs to regulate transcription. It is unknown whether a single transcription factor is able to bind to distinctly different motifs on chromatin, and if so, what determines the usage of specific motifs. By using a motif-resolution chromatin immunoprecipitation-exonuclease (ChIP-exo) approach, we find that agonist-liganded human androgen receptor (AR) and antagonist-liganded AR bind to two distinctly different motifs, leading to distinct transcriptional outcomes in prostate cancer cells. Further analysis on clinical prostate tissues reveals that the binding of AR to these two distinct motifs is involved in prostate carcinogenesis. Together, these results suggest that unique ligands may switch DNA motifs recognized by ligand-dependent transcription factors in vivo. Our findings also provide a broad mechanistic foundation for understanding ligand-specific induction of gene expression profiles.

Adrenal gland inclusions in patients treated with aldosterone antagonists (Spironolactone/Eplerenone): incidence, morphology, and ultrastructural findings

Abstract

Background

Spironolactone is often used to treat hypertension caused by hyperaldosteronism, and as a result, can form concentrically laminated electron dense spironolactone body inclusions within the adrenal gland. Spironolactone bodies have not been investigated in a contemporary cohort or in patients treated with the more recently approved aldosterone antagonist, eplerenone.

Methods

Spironolactone bodies were retrospectively investigated in patients treated for hyperaldosteronism (n = 15) from 2012-2013 that underwent a subsequent adrenalectomy.

Results

Inclusions were identified in 33% of patients treated with aldosterone antagonists, far less than previously reported. Remarkably, 50% of patients treated with spironolactone had inclusions while no patients using eplerenone alone had inclusions. Two patients treated with spironolactone had bodies present longer than the duration described in prior studies. Inclusions unexpectedly persisted in 1 patient despite increased duration of discontinued pharmacological treatment. A spectrum of histologic and ultrastructural findings were encountered within an adrenal cortical adenoma from a patient treated with both spironolactone and eplerenone. Ultrastructural examination revealed laminated electron dense bodies with the appearance of classic spironolactone inclusions as well as electron dense bodies without laminations and laminated bodies without electron dense cores.

Conclusions

Our incidence rate of spironolactone bodies was much lower than previously reported, with no inclusions seen in patients treated solely with the newer aldosterone antagonist, eplerenone. Pathologists should be aware of these infrequently encountered inclusions, particularly as the clinical history of hyperaldosteronism and pharmacologic treatment may not be provided.

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/4597918761268031

Enhanced enrichment of prostate cancer stem-like cells with miniaturized 3D culture in liquid core-hydrogel shell microcapsules

Cancer stem-like cells (CSCs) are rare subpopulations of cancer cells that are reported to be responsible for cancer resistance and metastasis associated with conventional cancer therapies. Therefore, effective enrichment/culture of CSCs is of importance to both the understanding and treatment of cancer. However, it usually takes approximately 10 days for the widely used conventional approach to enrich CSCs through the formation of CSC-containing aggregates. Here we report the time can be shortened to 2 days while obtaining prostate CSC-containing aggregates with better quality based on the expression of surface receptor markers, dye exclusion, gene and protein expression, and in vivo tumorigenicity. This is achieved by encapsulating and culturing human prostate cancer cells in the miniaturized 3D liquid core of microcapsules with an alginate hydrogel shell. The miniaturized 3D culture in core-shell microcapsules is an effective strategy for enriching/culturing CSCs in vitro to facilitate cancer research and therapy development.

Prediction of chemotherapeutic response in bladder cancer using K-means clustering of dynamic contrast-enhanced (DCE)-MRI pharmacokinetic parameters

PURPOSE

To apply k-means clustering of two pharmacokinetic parameters derived from 3T dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to predict the chemotherapeutic response in bladder cancer at the mid-cycle timepoint.

MATERIALS AND METHODS

With the predetermined number of three clusters, k-means clustering was performed on nondimensionalized Amp and kep estimates of each bladder tumor. Three cluster volume fractions (VFs) were calculated for each tumor at baseline and mid-cycle. The changes of three cluster VFs from baseline to mid-cycle were correlated with the tumor's chemotherapeutic response. Receiver-operating-characteristics curve analysis was used to evaluate the performance of each cluster VF change as a biomarker of chemotherapeutic response in bladder cancer.

RESULTS

The k-means clustering partitioned each bladder tumor into cluster 1 (low kep and low Amp), cluster 2 (low kep and high Amp), cluster 3 (high kep and low Amp). The changes of all three cluster VFs were found to be associated with bladder tumor response to chemotherapy. The VF change of cluster 2 presented with the highest area-under-the-curve value (0.96) and the highest sensitivity/specificity/accuracy (96%/100%/97%) with a selected cutoff value.

CONCLUSION

The k-means clustering of the two DCE-MRI pharmacokinetic parameters can characterize the complex microcirculatory changes within a bladder tumor to enable early prediction of the tumor's chemotherapeutic response.

Rethinking the value of sending vasectomy specimens for histologic examination: an analysis of arterial vasculature and failure to transect the vas deferens

OBJECTIVES

The testicular, deferential, and cremasteric arteries and their branches surround the vas deferens (VD), leaving them susceptible to injury during vasectomy. Literature describing the caliber of arteries seen in vasectomy specimens is lacking, making it difficult to categorize the significance of an observed artery. We aimed to establish reference values for arterial size typically encountered in vasectomy specimens and assess our institutional experience with failure to transect the VD.

METHODS

The luminal diameter of the largest artery in 231 consecutive VD specimens from 116 patients was measured microscopically. For comparison, the diameter of the largest artery within 10 spermatic cord cross-sections from inguinal orchiectomies was obtained. The immediate vasectomy failure rate based on histologic assessment was calculated using specimens from 2008 to 2012.

RESULTS

The luminal diameter of the largest artery encountered in a vasectomy specimen was 1.00 mm or less in 96.5% of cases. Artery sizes greater than or equal to 2.50 mm were only seen in spermatic cord resections. From 2008 to 2012, three (0.36%) of 837 patients undergoing vasectomy had specimens that showed failure to transect both VD.

CONCLUSIONS

Although the American Urologic Association and European Association of Urology state that histologic evaluation of vasectomy specimens is not required, we encourage the surgeon to send VD specimens for histologic examination. Doing so allows early identification of the failure to transect the VD and the resection of surrounding vasculature, providing quality control feedback to the surgeon.