Proceedings of the 2024 North American Society of Head and Neck Pathology Companion Meeting, Baltimore, MD, March 24, 2024: Navigating Ancillary Studies in Basaloid/Blue Salivary Tumors

BACKGROUND

Basaloid salivary tumors can demonstrate significant morphologic overlap and be challenging to diagnose.

METHODS

A review of select ancillary studies in basaloid salivary tumors was performed.

RESULTS

A number of immunohistochemical stains, including PLAG1, HMGA2, β-catenin, MYB, and RAS Q61R, have been more recently incorporated into the diagnostic workup of basaloid salivary tumors.

CONCLUSIONS

Although reported variability in their performance has perhaps limited their widespread adoption, these immunohistochemical studies can nevertheless be useful in supporting pathologic diagnoses, particularly when considered in more specific differentials or when used as a panel with other markers.

Nivolumab for Patients With High-Risk Oral Leukoplakia: A Nonrandomized Controlled Trial

Importance

Proliferative verrucous leukoplakia (PVL) is an aggressive oral precancerous disease characterized by a high risk of transformation to invasive oral squamous cell carcinoma (OSCC), and no therapies have been shown to affect its natural history. A recent study of the PVL immune landscape revealed a cytotoxic T-cell-rich microenvironment, providing strong rationale to investigate immune checkpoint therapy.

Objective

To determine the safety and clinical activity of anti-programmed cell death 1 protein (PD-1) therapy to treat high-risk PVL.

Design, Setting, and Participants

This nonrandomized, open-label, phase 2 clinical trial was conducted from January 2019 to December 2021 at a single academic medical center; median (range) follow-up was 21.1 (5.4-43.6) months. Participants were a population-based sample of patients with PVL (multifocal, contiguous, or a single lesion ≥4 cm with any degree of dysplasia).

Intervention

Patients underwent pretreatment biopsy (1-3 sites) and then received 4 doses of nivolumab (480 mg intravenously) every 28 days, followed by rebiopsy and intraoral photographs at each visit.

Main Outcomes and Measures

The primary end point was the change in composite score (size and degree of dysplasia) from before to after treatment (major response [MR]: >80% decrease in score; partial response: 40%-80% decrease). Secondary analyses included immune-related adverse events, cancer-free survival (CFS), PD-1 ligand 1 (PD-L1) expression, 9p21.3 deletion, and other exploratory immunologic and genomic associations of response.

Results

A total of 33 patients were enrolled (median [range] age, 63 [32-80] years; 18 [55%] were female), including 8 (24%) with previously resected early-stage OSCC. Twelve patients (36%) (95% CI, 20.4%-54.8%) had a response by composite score (3 MRs [9%]), 4 had progressive disease (>10% composite score increase, or cancer). Nine patients (27%) developed OSCC during the trial, with a 2-year CFS of 73% (95% CI, 53%-86%). Two patients (6%) discontinued because of toxic effects; 7 (21%) experienced grade 3 to 4 immune-related adverse events. PD-L1 combined positive scores were not associated with response or CFS. Of 20 whole-exome sequenced patients, all 6 patients who had progression to OSCC after nivolumab treatment exhibited 9p21.3 somatic copy-number loss on pretreatment biopsy, while only 4 of the 14 patients (29%) who did not develop OSCC had 9p21.3 loss.

Conclusions and Relevance

This immune checkpoint therapy precancer nonrandomized clinical trial met its prespecified response end point, suggesting potential clinical activity for nivolumab in high-risk PVL. Findings identified immunogenomic associations to inform future trials in this precancerous disease with unmet medical need that has been difficult to study.

Trial Registration

ClinicalTrials.gov Identifier: NCT03692325.

Degenerative atypia in benign thyroid nodules: a potential diagnostic pitfall on fine-needle aspiration

INTRODUCTION

Benign (B) follicular lesions of the thyroid are among the most encountered specimens on fine needle aspiration (FNA). Although FNA and The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) remain highly accurate, minimally invasive and robust tools in triaging thyroid nodules, false positive (FP) diagnoses may still occur. Endocrine-type degenerative atypia can cause diagnoses of suspicious for malignancy (SFM) or malignant (M), resulting in overtreatment and exposure to undue surgical risk in patients.

MATERIALS AND METHODS

We performed a multi-institutional retrospective clinicopathologic correlation of benign thyroid nodules with degenerative atypia on FNA. Review of cytologic material was conducted to identify potential cytomorphologic features which may have prompted these diagnoses.

RESULTS

Among 342 patients with benign thyroid nodules harboring degenerative atypia, 123 had available preceding FNA cytopathology. TBSRTC nondiagnostic, B, atypia of undetermined significance, follicular neoplasm, SFM, and M, comprised 3.3%, 49.6%, 30.1%, 13.0%, 2.4%, and 1.6% of cases. Among patients with FP diagnoses (SFM and M), 100% underwent total thyroidectomy, and 40.0% underwent additional neck lymph node dissections. Among remaining patients, 61.0%, 39.0%, and 0% underwent lobectomy, thyroidectomy, and lymph node dissection. The number of patients who underwent total thyroidectomy was significantly different (P = 0.03) between those with FP nodules and those without.

CONCLUSIONS

We demonstrate that 4.1% of nodules harboring endocrine-type degenerative atypia may be given FP diagnoses on initial FNA. Such atypia may be indistinguishable from that of Graves' Disease, dyshormonogenic goiter, and radiation therapy. FP diagnoses of degenerative atypia can expose patients to undue surgical procedures and risks.

Challenges in Encapsulated Follicular-Patterned Tumors: How Much Is Enough? Evaluation of Nuclear Atypia, Architecture, and Invasion

Thyroid pathology is notoriously fraught with high interobserver variability, and follicular-patterned tumors are among some of the most challenging to assess accurately and reproducibly. Given that encapsulated or well-circumscribed follicular-patterned tumors often have similar molecular profiles, that is, frequent RAS or RAS-like alterations, the diagnosis usually relies on histopathologic examination alone. Unfortunately, many of the features that are used for diagnosis and prognosis of these tumors have long been controversial and frequently debated topics, both due to their subjectivity and their evolving (or not yet resolved) definitions. In more recent years, the introduction of noninvasive follicular thyroid neoplasm with papillary-like nuclear features has added further complexity to this discussion. In particular, the criteria and significance of nuclear features of papillary thyroid carcinoma, architectural patterns, and invasive growth still pose significant diagnostic challenges and confusion. This review explores some of the challenges in evaluating encapsulated follicular-patterned tumors, focusing on those histologic elements.

Grading of Medullary Thyroid Carcinoma: an Interobserver Reproducibility Study

Grade, based on proliferative activity and tumor necrosis, has recently been shown to be prognostic in medullary thyroid carcinoma (MTC) in multivariate analysis. The aim of this study was to evaluate the interobserver reproducibility of assessed grade in MTC. Three groups (each group included one resident/fellow and one attending pathologist) independently evaluated a cohort of 44 sporadic MTC. For each case, all available tumor slides were reviewed, and mitotic count and the presence of tumor necrosis were recorded. Ki-67 was performed, and the Ki-67 proliferative index was determined in the area of highest proliferative activity. Tumors were graded according to the recently published International Medullary Thyroid Carcinoma Grading System (IMTCGS). Kappa statistics were calculated for each individual criterion (mitotic count, Ki-67 proliferative index, and necrosis) and for assigned IMTCGS grade. For our cohort of 44 MTCs, the kappa statistic for mitotic count, Ki-67 proliferative index, and necrosis was 0.68, 0.86, and 0.89, respectively. The kappa statistic for assigned IMTCGS grade was 0.87. Our findings indicate that there was a strong level of agreement for assessment of grade in our cohort of MTC, indicating that grade as assessed by the IMTCGS is not only prognostic but also reproducible.

The new endocrine WHO classification: What does this mean for thyroid cytology?

The new World Health Organization classification of endocrine tumors will include many updates on thyroid pathology. This summary highlights the changes that are most relevant for cytopathologists.

Papillary Thyroid Carcinoma with High-Grade Features Versus Poorly Differentiated Thyroid Carcinoma: An Analysis of Clinicopathologic and Molecular Features and Outcome

Background: Similar to poorly differentiated thyroid carcinoma (PDTC), papillary thyroid carcinoma with high-grade features (PTC HGF) demonstrates increased mitotic activity and/or necrosis; however, PTC HGF is excluded from the World Health Organization (WHO) definition of PDTC based on maintained nuclear features of PTC. Methods: Consecutive tumors that met criteria for PTC HGF, defined as tumors with maintained nuclear features of PTC and mitoses numbering 5 or more per 10 contiguous high-power fields and/or tumor necrosis, and PDTC (defined as per the WHO criteria) were identified. Clinicopathologic characteristics, follow-up data, and targeted next-generation sequencing results were compared between groups. Results: There were 15 PTC HGF and 47 PDTC. PTC HGF was associated with a higher rate of pT4 disease (53% vs. 13%, p = 0.0027) and lymph node metastases (73% vs. 38%, p = 0.049). The disease-specific survival was worse for patients with PTC HGF compared with those with PDTC using Kaplan-Meier estimation (p < 0.001) and was worse in subgroup analysis evaluating patients with widely invasive PDTC (i.e., those with a similar rate of pT4 disease) and PTC HGF (p = 0.040). PTC HGF had a higher BRAF^V600E mutation rate (42% vs. 3%; p = 0.003), a trend toward more gene fusions (25% vs. 3%; p = 0.052), and a higher rate of relative gain of 1q (67% vs. 15%; p = 0.002) than PDTC. Conclusions: Our results demonstrate that PTC HGF are important to recognize based on their aggressive behavior. The molecular differences between PTC HGF and PDTC suggest that PTC HGF should be considered a distinct group from PDTC.

Genomic profile of columnar cell variant of papillary thyroid carcinoma

BACKGROUND AND AIMS

Columnar cell variant (CCV) is a rare papillary thyroid carcinoma subtype. The majority of CCV occur in older patients and are large, invasive tumours that pursue an aggressive clinical course. Rare well-circumscribed CCV occur in younger female patients and are comparatively indolent.

METHODS AND RESULTS

We retrospectively identified CCV with material available to perform targeted next-generation sequencing and correlated molecular results with clinicopathological features and outcome. Our cohort was comprised of nine CCV. Nearly all were aggressive tumours; however, one was predominantly well-circumscribed and arose in a thyroglossal duct cyst of a 26-year-old woman who had no evidence of disease at last follow-up. Seven (78%) cases demonstrated activating oncogenic driver alterations in BRAF, including BRAF V600E, an activating N486_P490del deletion, and BRAF-AGK fusions. Activating RAS mutations were seen in two (22%) cases. Additionally, three (33%) cases had TERT promoter mutations, four (44%) had loss of the tumour suppressor CDKN2A and one (11%) case had a loss of function TP53 mutation. Most cases (89%) also demonstrated copy number alterations, including recurrent gain of chromosome 1q (five cases) and losses of chromosome 9p (three cases) and 22q (four cases). The one case without secondary pathogenic mutations or copy number alterations was the tumour in the 26-year-old woman.

CONCLUSIONS

We found that CCV is primarily a BRAF-driven tumour, with most also harbouring secondary oncogenic mutations and multiple chromosomal gains and losses. Moreover, our findings suggest that molecular analysis could potentially be used to help risk stratify CCV.

Hürthle cell lesions of the thyroid: Progress made and challenges remaining

Hürthle cell-predominant thyroid fine needle aspirations (FNA) are encountered frequently in routine practice, yet they are often challenging to diagnose accurately and are associated with significant interobserver variability. This is largely due to the ubiquity of Hürthle cells in thyroid pathology, ranging from nonneoplastic conditions to aggressive malignancies. Although limitations in cytomorphologic diagnoses likely will remain for the foreseeable future, our knowledge of the molecular pathogenesis of Hürthle cell neoplasia and application of molecular testing to cytologic material have increased dramatically within the past decade. This review provides context behind the challenges in diagnosis of Hürthle cell lesions and summarizes the more recent advances in diagnostic tools.

Assessment of a Personal Interactive Carbon Monoxide Breath Sensor in People Who Smoke Cigarettes: Single-Arm Cohort Study

Background

Tobacco use is the leading cause of preventable morbidity and mortality. Existing evidence-based treatments are underutilized and have seen little recent innovation. The success of personal biofeedback interventions in other disease states portends a similar opportunity in smoking cessation. The Pivot Breath Sensor is a personal interactive FDA-cleared (over-the-counter) device that measures carbon monoxide (CO) in exhaled breath, enabling users to link their smoking behavior and CO values, and track their progress in reducing or quitting smoking.

Objective

The objective of this study is to assess the Pivot Breath Sensor in people who smoke cigarettes, evaluating changes in attitudes toward quitting smoking, changes in smoking behavior, and use experience.

Methods

US adults (18-80 years of age, ≥10 cigarettes per day [CPD]) were recruited online for this remote 12-week study. Participants completed a screening call, informed consent, and baseline questionnaire, and then were mailed their sensor. Participants were asked to submit 4 or more breath samples per day and complete questionnaires at 1-4, 8, and 12 weeks. Outcomes included attitudes toward quitting smoking (Stage of Change, success to quit, and perceived difficulty of quitting), smoking behavior (quit attempts, CPD reduction, and 7-, 30-day point prevalence abstinence [PPA]), and use experience (impact and learning).

Results

Participants comprised 234 smokers, mean age 39.9 (SD 11.3) years, 52.6% (123/234) female, mean CPD 20.3 (SD 8.0). The 4- and 12-week questionnaires were completed by 92.3% (216/234) and 91.9% (215/234) of participants, respectively. Concerning attitude outcomes, at baseline, 15.4% (36/234) were seriously thinking of quitting in the next 30 days, increasing to 38.9% (84/216) at 4 weeks and 47.9% (103/215) at 12 weeks (both P<.001). At 12 weeks, motivation to quit was increased in 39.1% (84/215), unchanged in 54.9% (118/215), and decreased in 6.0% (13/215; P<.001). Additional attitudes toward quitting improved from baseline to 12 weeks: success to quit 3.3 versus 5.0 (P<.001) and difficulty of quitting 2.8 versus 4.3 (P<.001). Regarding smoking behavior, at 4 weeks, 28.2% (66/234) had made 1 or more quit attempts (≥1 day of abstinence), increasing to 48.3% (113/234) at 12 weeks. At 4 weeks, 23.1% (54/234) had reduced CPD by 50% or more, increasing to 38.5% (90/234) at 12 weeks. At 12 weeks, CPD decreased by 41.1% from baseline (P<.001), and 7- and 30-day PPA were 12.0% (28/234) and 6.0% (14/234), respectively. Concerning use experience, 75.3% (171/227) reported the sensor increased their motivation to quit. More than 90% (>196/214) indicated the sensor taught them about their CO levels and smoking behavior, and 73.1% (166/227) reported that seeing their CO values made them want to quit smoking.

Conclusions

Use of the Pivot Breath Sensor resulted in a significant increase in motivation to quit, a reduction in CPD, and favorable quit attempt rates. These outcomes confer increased likelihood of quitting smoking. Accordingly, the results support a role for biofeedback via personal CO breath sampling in smoking cessation.

Trial Registration

ClinicalTrials.gov NCT04133064; https://clinicaltrials.gov/ct2/show/NCT04133064

Histopathologic Features and Clinical Outcome of Anaplastic Thyroid Carcinoma with a Minor Anaplastic Component

Although prior studies have reported that patients with anaplastic thyroid carcinoma (ATC) with a focal anaplastic component may have a prolonged survival compared to other ATC patients, the outcome data are limited. We evaluated a cohort of ATC resected between 2003 and 2018. Tumor slides were reviewed to confirm the diagnosis and to identify cases with a minor ATC component (defined as comprising < 10% of the tumor). We evaluated the clinical outcome of these patients compared to that of all other cohort patients (characterized as having conventional ATC). Our cohort was composed of 24 cases of ATC that underwent resection, including 8 (33%) with a minor ATC component. Tumors with a minor ATC component were predominantly associated with papillary thyroid carcinoma. For patients with tumors with a minor ATC component, the 1-year and 2-year survival rates and median survival for patients who died of disease were 88%, 43%, and 17 months (range 6-73 months), respectively. In comparison, for patients with conventional ATC, the 1-year and 2-year survival rates and median survival for patients who died of disease were 56%, 44%, and 7 months (range 2-26 months), respectively. There was no difference in 1- and 2-year survival or overall survival by Kaplan-Meier analysis for patients with tumors with a minor ATC component and those with conventional ATC. In conclusion, the difference in overall survival between ATC groups in our cohort was not significant; however, this could be due to the small cohort size or due to characteristics of our group with a minor ATC component; that is, no tumors in this group were limited to the thyroid (stage IVA), resectability with negative margins was infrequent, and 38% of this group had distant metastases at diagnosis (stage IVC).

Histological features of BRAF V600E-mutant anaplastic thyroid carcinoma

AIMS

Treatment with a BRAF inhibitor, alone or in combination with a MEK inhibitor, may be considered for BRAF-mutant anaplastic thyroid carcinoma (ATC). The purpose of this study was to characterise the histology of BRAF V600E-mutant ATC.

METHODS AND RESULTS

We identified 28 ATC that were consecutively resected between 2003 and 2019. All tumour slides for each case were evaluated for the presence of a precursor tumour and for ATC morphology (sarcomatoid, pleomorphic giant cell, epithelioid or squamous). BRAF V600E mutation status was determined by BRAF V600E IHC or molecular analysis (OncoPanel NGS). Eighteen (64%) ATC had an associated well-differentiated precursor, including 10 (36%) with associated papillary thyroid carcinoma (PTC) and eight (29%) with associated follicular thyroid carcinoma (FTC) or Hürthle cell carcinoma (HCC). Most ATC (19 cases, 68%) demonstrated a mixed anaplastic morphology. Squamous morphology was present in four cases. Ten (36%) ATC had a BRAF V600E mutation. All ATC that had a PTC precursor had a BRAF V600E mutation (and all ATC with a BRAF V600E mutation had a PTC precursor), whereas no ATC with an FTC or HCC precursor had a BRAF V600E mutation. All four cases of ATC with a squamous morphology had a PTC precursor and a BRAF V600E mutation.

CONCLUSION

In our cohort, the presence of a PTC precursor predicted the presence of the BRAF V600E mutation, whereas ATC with an FTC or HCC precursor lacked a BRAF V600E mutation. A squamous morphology was associated with the presence of a PTC precursor and a BRAF V600E mutation.

Thyroid Tumors You Don't Want to Miss

This article examines more uncommon thyroid entities, including anaplastic thyroid carcinoma, poorly differentiated thyroid carcinoma, rare papillary thyroid carcinoma variants, medullary thyroid carcinoma, non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), and multiple adenomatous nodules in the setting of Cowden syndrome. These entities were chosen based on their clinical significance and because they can be diagnostically challenging due to their morphologic diversity and overlap with other thyroid tumors. This article addresses the diagnostic features of each entity, focusing on how to avoid potential pitfalls and mimics while also highlighting the clinical implications of each diagnosis.

Malignancy risk for solitary and multiple nodules in Hürthle cell-predominant thyroid fine-needle aspirations: A multi-institutional study

BACKGROUND

Hürthle cell metaplasia is common in hyperplastic nodules, particularly within the setting of lymphocytic thyroiditis (LT). The Bethesda System for Reporting Thyroid Cytopathology indicates that it is acceptable to classify Hürthle cell-predominant fine-needle aspiration (HC FNA) specimens as atypia of undetermined significance (AUS) rather than suspicious for a Hürthle cell neoplasm (HUR) within the setting of multiple nodules or known LT. The goal of the current study was to address whether this approach is justified.

METHODS

HC FNA specimens were identified and correlated with ultrasound and surgical pathology reports if available. Multinodularity was determined based on findings on macroscopic examination if imaging results were unavailable.

RESULTS

A total of 698 HC FNA specimens were identified, including 576 resected nodules, 455 of which (79%) were benign. The overall risk of malignancy for HUR was 27%, whereas the risk of malignancy for AUS was 10%. The mean size of the benign nodules was 2.1 cm on surgical resection specimens, with multiple nodules noted in 293 cases (64%) and histologic LT noted in 116 cases (25%). The mean size of the malignant nodules was 2.8 cm, with multiple nodules and histologic LT noted in 74 cases (61%) and 22 cases (18%), respectively. The malignancy rate did not differ between solitary or multiple nodules (P = .52) or in the presence or absence of LT (P = .12). However, size did significantly differ between malignant and benign nodules (P < 0.01).

CONCLUSIONS

The malignancy rate did not differ significantly in the presence of multiple nodules or LT, although the latter demonstrated a statistical trend. A diagnosis of AUS over HUR based solely on the presence of multinodularity is not warranted.

Heterogeneity of p16 immunohistochemistry and increased sensitivity of RNA in situ hybridization in cytology specimens of HPV-related head and neck squamous cell carcinoma

BACKGROUND

Many patients with human papillomavirus (HPV)-related head and neck squamous cell carcinoma (HPV-HNSCC) initially present with cervical lymph node metastases. Although p16 immunohistochemistry (IHC) is the most commonly used surrogate marker for HPV, however criteria in cytologic material are not well established. The objective of this study was to better characterize p16 IHC in cell blocks of metastatic HPV-HNSCC, and to evaluate the performance of HPV RNA in situ hybridization (RNA ISH).

METHODS

p16 IHC was performed on cell blocks from 97 metastatic HPV-HNSCC fine-needle aspiration specimens with HPV status confirmed by DNA or RNA ISH or polymerase chain reaction (PCR). Tumor cellularity (<100 cells, 100-500 cells, and >500 cells) and quality (presence of cell clusters, necrosis) were recorded. p16 staining intensity and extent (1%-9%, 10%-69%, and ≥70%) were scored. In addition, RNA ISH was performed on 38 PCR-positive cases.

RESULTS

p16 IHC was positive in 90 of 97 cases (93%), demonstrating variable patterns. p16 staining was found to be moderate to strong in 69 cases, with 37 cases (38%) demonstrating positivity in ≥70% of tumor cells. Weak staining occurred in 21 cases (22%) and 7 cases (7%) were negative. Of the 60 cases with weak and/or absent expression or staining in <70% of cells, 30 cases (50%) had <100 tumor cells, 12 (20%) lacked cell clusters, and 19 cases (32%) had extensive necrosis. RNA ISH was positive in 37 of 38 cases (97%) that were HPV positive by PCR.

CONCLUSIONS

p16 is heterogeneous in cell blocks of metastatic HPV-HNSCC, suggesting that any p16 positivity should prompt confirmatory HPV studies. RNA ISH appears to demonstrate high sensitivity, and laboratories even may consider using RNA ISH as a first-line HPV test in cytologic specimens.

Prognostic Significance of Extent of Invasion in Poorly Differentiated Thyroid Carcinoma

Background: The 2017 World Health Organization (WHO) Classification of Tumors of Endocrine Organs defines poorly differentiated thyroid carcinoma (PDTC) as a tumor with conventional criteria of malignancy (capsular penetration or vascular invasion) with solid, insular, or trabecular growth, a lack of nuclear features of papillary thyroid carcinoma, and increased mitotic activity, tumor necrosis, or convoluted nuclei. The extent of invasion has been shown to be prognostic in follicular thyroid carcinoma and Hürthle cell carcinoma. Our aim was to evaluate how extent of invasion impacts clinical outcome for PDTC. Methods: We retrospectively identified 47 consecutively diagnosed cases of PDTC that were resected between 2005 and 2018. All cases were reviewed to confirm that the tumors met the 2017 Endocrine WHO criteria of PDTC. In addition, tumors were categorized as follows: encapsulated with capsular penetration only, encapsulated with focal vascular invasion (fewer than four foci), encapsulated with extensive vascular invasion (four or more foci), or widely invasive. Histopathologic characteristics and clinical outcome data were recorded. Results: A total of 47 cases of PDTC, including 15 oncocytic tumors, were identified from 28 (60%) women and 19 (40%) men (mean age of 57 years at diagnosis). The mean tumor size was 4.3 cm. Mitoses numbered 8 per 10 high-power fields (HPF) on average (range: 1-34), and necrosis was present in 21 (45%) cases. Eight (17%) cases were encapsulated with capsular penetration only, 5 (11%) were encapsulated with focal vascular invasion, 18 (38%) were encapsulated with extensive vascular invasion, and 16 (34%) were widely invasive. Of the 42 (89%) patients with follow-up data, 7 (17%) died of disease (with a mean survival time of 6.4 years), 11 (26%) have distant metastatic disease, and 24 (57%) have no evidence of disease (mean follow-up 5.6 years). Eight (19%) patients presented with M1 disease at diagnosis. The 5-year disease-free survival (DFS) for patients with M0 disease at diagnosis was 100% for patients with tumors with capsular invasion only or focal vascular invasion (n = 7), 73% for patients with encapsulated tumors with extensive vascular invasion (n = 11), and 17% for patients with widely invasive PDTCs (n = 6). DFS estimates by Kaplan-Meier analysis were significantly different between these groups (p = 0.0016). Conclusions: Extent of invasion appears to be an important parameter that affects clinical outcome for patients with PDTC. In our cohort, patients with encapsulated PDTC with capsular invasion only or focal vascular invasion had an excellent outcome.

Clinicopathologic Features of Mismatch Repair-Deficient Anaplastic Thyroid Carcinomas

Background: Prior studies have reported mutations in mismatch repair (MMR) genes in a small subset of anaplastic thyroid carcinomas (ATC). The aim of this study was to identify MMR-protein-deficient (MMR-D) ATC and investigate their histopathologic features and clinical outcome. Methods: A cohort of 28 ATC diagnosed between 2003 and 2017 with tissue blocks available were evaluated. Immunohistochemistry for MMR proteins was performed to identify MMR-D tumors. Clinicopathologic features, molecular findings (determined by a targeted next-generation sequencing assay), and clinical outcome data for MMR-D tumors were recorded and compared to that of MMR-protein-intact (MMR-I) tumors. Results: There were four (14%) MMR-D ATC, all of which showed complete loss of MSH2 and MSH6 with intact expression of MLH1 and PMS2. Three of these tumors had MSH2 mutations and a hypermutated phenotype by next-generation sequencing. All four patients (two male; M_age at diagnosis = 64 years) presented with stage IVB disease (i.e., gross extrathyroidal extension or a lymph node metastasis at presentation). There were no differences in tumor size or rates of gross extrathyroidal extension, lymph node metastases, or positive resection margins between MMR-D and MMR-I ATC. Patients with MMR-D tumors were less likely to have distant metastatic disease at presentation (p = 0.035), although half did eventually develop distant metastases. MMR-D tumors were not histologically distinct. All four patients with MMR-D tumors lived for more than one year. One patient died of disease at 15 months, while the remaining three were alive at last follow-up, with survival of 19, 38, and 48 months. Patients with MMR-D ATC had significantly better survival compared to those with MMR-I tumors (p = 0.033), which was maintained when considering only patients with stage IVB disease at presentation (p = 0.030). Conclusion: MMR-D tumors comprised 14% of this ATC cohort. Although the findings must be interpreted with caution given the small number of MMR-D ATC in the cohort, the results suggest that MMR status may be prognostically significant in ATC.

Tall Cell Variant of Papillary Thyroid Carcinoma: Impact of Change in WHO Definition and Molecular Analysis

The morphologic criteria for tall cell variant (TCV) of papillary thyroid carcinoma (PTC) were modified in the 2017 WHO Classification of Tumors of Endocrine Organs, with a decrease in the requirements for both the height of cells and in the percentage of tumor demonstrating a tall cell morphology. The aim of this study was to determine if the change in criteria would result in a significant increase in the percentage of tumors that meet criteria for TCV. In addition, we evaluated the correlation between morphology, molecular alterations, and clinical behavior of TCV. We studied three cohorts to evaluate the above stated questions. The first cohort was comprised of 97 PTC consecutively resected over a 12-month period that were originally diagnosed as classic PTC, PTC with tall cell features, or TCV. Tumor slides of each case were reviewed to determine the percentage of the tall cell component (< 30%, 30-49%, and > 50%) and the height of the cells in this component. This cohort was evaluated to determine if the change in WHO criteria would result in a significant increase in the percentage of tumors that meet criteria for TCV. Our second cohort consisted of nine consecutively resected PTC with a tall cell component > 30% (with tall cells defined as at least 2-3× as tall as wide) that had molecular characterization through a targeted, next-generation sequencing (NGS) assay. The molecular characteristics were correlated with the percentage of the tall cell component. Finally, a third cohort comprised of seven clinically aggressive TCV (defined as those with T4 disease, disease recurrence, or subsequent tumor dedifferentiation) was evaluated to determine histologic and molecular characteristics. In cohort 1, the number of cases classified as TCV increased significantly with the change in definition of TCV: 8 (8%) cases met the previous criteria for TCV (cells 3× as tall as wide in > 50% of the tumor), whereas 24 (25%) cases met the new 2017 WHO criteria (cells 2-3× as tall as wide in > 30% of the tumor) (p = 0.0020). Molecular analysis of cohort 2 revealed that all 9 cases harbored a BRAF V600E mutation. Pathogenic secondary mutations were absent in cases with < 50% tall cells, but they were detected in 2 (33%) of 6 cases with > 50% tall cells (2 cases with TERT promoter mutations, including 1 that also had an AKT2 mutation). Histologic and molecular analysis of the clinically aggressive cohort (cohort 3), revealed that all cases had > 50% tall cells and 3 (43%) had secondary oncogenic mutations (all TERT promoter mutations). We found that the modified morphologic criteria put forth in the 2017 WHO tripled the number of cases that would be classified as TCV. Moreover, clinically aggressive tumors and those harboring secondary oncogenic mutations all had a tall cell component > 50%. Additional large multi-institutional studies incorporating clinical outcome and molecular data would be valuable to determine the best histologic definition of TCV.

Effect of a financial incentive on the acceptance of a smoking cessation programme with service charge: a cluster-controlled trial

INTRODUCTION

Frontline health care professionals in Hong Kong may encounter high refusal rates for the Hospital Authority's Smoking Counselling and Cessation Programme (SCCP) when smokers know it is subject to a service charge. We compared SCCP booking and attendance rates among smokers with or without a financial incentive.

METHODS

In this multicentre non-randomised cluster-controlled trial, adult smokers who attended one of six general out-patient clinics between November 2015 and April 2016 were invited to join an SCCP. Attendees in the three intervention-group centres but not the three control-group centres received a supermarket coupon to offset the service charge.

RESULTS

A total of 173 smokers aged 18 years or older (92 in the intervention group and 81 in the control group) were recruited into the study. In the intervention group, 47 smokers (51%) agreed via a questionnaire that they would join the SCCP, compared with only 23 smokers in the control group (28%). The booking rates were 83% (n=39) in the intervention group and 83% (n=19) in the control group. Among those who had booked a place, 19 (49%) intervention-group participants and 11 (58%) control-group participants attended an SCCP session. Multivariable logistic regression revealed that offering a coupon was associated with agreeing to join an SCCP (odds ratio=4.963, 95% confidence interval=2.173-11.334; P<0.001) and booking an SCCP place (odds ratio=4.244, 95% confidence interval=1.838-9.799; P<0.001).

CONCLUSION

Provision of a financial incentive was positively associated with agreement to join an SCCP and booking an SCCP place. Budget holders should consider providing the SCCP free of charge to increase smokers' access to the service.

Cytologic diagnosis of round cell sarcomas in the era of ancillary testing: an updated review

Round cell sarcomas constitute a large proportion of "small round blue cell tumors," which encompass a broad differential diagnosis and can be difficult to distinguish on cytomorphologic grounds alone. Numerous pathogenetic insights and advances in ancillary testing in soft tissue pathology over the last several decades have made accurate classification of soft tissue neoplasms increasingly feasible. Immunohistochemistry and genetic/molecular testing can now be performed on all cytologic preparations, including unstained smears, needle rinses, cell blocks, and liquid-based preparations, and this has greatly increased our diagnostic abilities. Nevertheless, there remain numerous diagnostic challenges, including variable sensitivity and specificity of available immunohistochemical markers, overlapping immunophenotypes between entities, and "promiscuity" of genetic alterations such as EWSR1 rearrangements, present in a multitude of tumor types. Herein we provide a review on the cytologic, immunohistochemical, and genetic features of the more frequently encountered round cell sarcomas, as well as recently described entities, with an emphasis on diagnostic pitfalls and judicious use of ancillary studies.

Translesional pressure gradient and leptomeningeal collateral status in symptomatic middle cerebral artery stenosis

BACKGROUND AND PURPOSE

Leptomeningeal collateral (LMC) status governs the prognosis of large artery occlusive stroke, although factors determining LMC status are not fully elucidated. The aim was to investigate metrics affecting LMC status in such patients by using computational fluid dynamics (CFD) models based on computed tomography angiography (CTA).

METHODS

In this cross-sectional study, patients with recent ischaemic stroke or transient ischaemic attack attributed to atherosclerotic M1 middle cerebral artery (MCA) stenosis (50%-99%) were recruited. Demographic, clinical and imaging data of these patients were collected. Ipsilesional LMC status was graded as good or poor by assessing the laterality of anterior and posterior cerebral arteries in CTA. A CFD model based on CTA was constructed to reflect focal hemodynamics in the distal internal carotid artery, M1 MCA and A1 anterior cerebral artery. Pressure gradients were calculated across culprit MCA stenotic lesions in CFD models. Predictors for good LMC status were sought in univariate and multivariate analyses.

RESULTS

Amongst the 85 patients enrolled (mean age 61.5 ± 10.9 years), 38 (44.7%) had good ipsilesional LMC status. The mean pressure gradient across MCA lesions was 14.8 ± 18.1 mmHg. Advanced age (P = 0.030) and a larger translesional pressure gradient (P = 0.029) independently predicted good LMCs. A lower fasting blood glucose level also showed a trend for good LMCs (P = 0.058).

CONCLUSIONS

Our study suggested a correlation between translesional pressure gradient and maturation of LMCs in intracranial atherosclerotic disease. Further studies with more exquisite and dynamic monitoring of cerebral hemodynamics and LMC evolution are needed to verify the current findings.

The Flip Side of NIFTP: an Increase in Rates of Unfavorable Histologic Parameters in the Remainder of Papillary Thyroid Carcinomas

The term noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was recently proposed to replace noninvasive follicular variant of papillary thyroid carcinoma (FVPTC) both to promote more conservative management of these tumors and spare patients the psychological burden of a cancer diagnosis. This reclassification will lower the incidence of papillary thyroid carcinoma (PTC). In addition, it could result in an increase in the rates of unfavorable histologic prognosticators for PTC overall because NIFTPs had previously accounted for many of the PTCs without these features. Our aim was to evaluate the potential impact of the reclassification of NIFTP on the rates of extrathyroidal extension, lymphovascular invasion, and lymph node metastases in PTC. We identified all PTCs clinically over 1 cm diagnosed on surgical resection between August 2010 and August 2012. The histopathologic characteristics, including PTC subtype, tumor size, presence of extrathyroidal extension and lymphovascular invasion, and surgical margin and lymph node status were all recorded. Based on these parameters, cases were classified according to the American Thyroid Association (ATA) risk stratification system for structural disease recurrence. Tumor slides for cases initially diagnosed as FVPTC were reviewed to identify tumors that would now be classified as NIFTPs. Our cohort included 348 cases of PTC, of which 94 (27%) would now be classified as NIFTPs. After excluding NIFTPs from the PTC category, there were increased rates of extrathyroidal extension (26% up from 19%, p = 0.046), lymphovascular invasion (37% up from 27%, p = 0.0099), and lymph node metastases (26% up from 19%, p = 0.045) among the remaining PTCs. Based on these changes in histologic features, 10% fewer cases were defined as ATA low risk (62% down from 72%, p = 0.0081). Our results indicate that the downgrading of some carcinomas to NIFTP will increase the rates of higher risk histologic parameters in the remaining PTCs by statistically significant margins. Although the overall survival for PTC is very high and would likely not be changed significantly by the introduction of NIFTP, additional studies evaluating the impact of the NIFTP shift are warranted.

Qualifiers of atypia in the cytologic diagnosis of thyroid nodules are associated with different Afirma gene expression classifier results and clinical outcomes

BACKGROUND

Thyroid nodules with atypia of undetermined significance (AUS) on fine‐needle aspiration (FNA) have a low risk of malignancy that appears to vary based on specific features described in the AUS diagnosis. The Afirma gene expression classifier (GEC) is a molecular test designed to improve preoperative risk stratification of thyroid nodules, but its performance for different patterns of AUS has not been defined. The objective of this study was to assess GEC results and clinical outcomes in AUS nodules with architectural atypia (AUS‐A), cytologic atypia (AUS‐C) or both (AUS‐C/A).

METHODS

This was a retrospective review of all thyroid nodules with AUS cytopathology that underwent GEC testing at the authors' institution over a period of >4 years.

RESULTS

In 227 nodules that had AUS cytology results and Afirma GEC testing, the rate of benign GEC results was higher in AUS‐A nodules (70 of 107; 65%) than in AUS‐C/A nodules (25 of 65; 38%; P = .0008), and AUS‐C nodules exhibited an intermediate rate of benign results (27 of 55 nodules; 59%). The risk of cancer among patients who had GEC‐suspicious nodules, 86% of whom underwent resection, was 19% (6 of 25) for AUS‐A nodules compared with 57% (21 of 37) for AUS‐C/A nodules (P = .003) and 45% (10 of 22) for AUS‐C nodules (P = .07). In nodules that had an indeterminate repeat cytology result, no difference was observed in the rate of benign GEC results or in the malignancy rate compared with nodules that had a single cytology result.

CONCLUSIONS

The performance characteristics of Afirma GEC testing vary, depending on qualifiers of cytologic atypia. Recognition of these differences may enable clinicians to provide improved counseling and treatment recommendations to patients. Cancer Cytopathol 2017;125:313–322. © 2017 American Cancer Society.

Thyroid nodules with atypia of undetermined significance cytology and Afirma gene expression classifier (GEC) testing are analyzed based on the presence of architectural, cytologic, or both cytologic and architectural atypia. Nodules with architectural atypia are the most likely to have a benign GEC result and least likely to be malignant, suggesting that clinicians should be aware of these cytologic qualifiers when advising patients regarding GEC testing and the risk of malignancy.

The prognosis of acute symptomatic seizures after ischaemic stroke

OBJECTIVE

Acute symptomatic seizure (AS) after ischaemic stroke is defined as a seizure occurring ≤7 days of the stroke. There remains a lack of information on the prognosis of AS after ischaemic stroke and how it should be treated.

METHODS

We prospectively recruited patients after their incidents of ischaemic stroke from a population-based stroke registry. Stroke aetiology was defined according to Trial-of-ORG-10172 in acute-stroke treatment (TOAST). Patients were examined for any transient complete-occlusion with recanalisation (TCOR) and haemorrhagic transformation. The seizure outcomes were (1) acute clustering of seizures ≤7 days, (2) seizure recurrence associated with stroke recurrence beyond the 7-day period and (3) unprovoked seizure (US) >7 days.

RESULTS

104 patients (mean age 65 years/55% female) with AS after ischaemic stroke were identified (mean follow-up 6.17 years). Comparison of the group of patients with AS and those without seizures showed that patients with AS had significantly less large-vessel and small-vessel disease but more cardioembolisms (p<0.05) and a higher proportion of TCOR (p<0.01), multiple territory infarcts (p=0.007) and haemorrhagic transformations (p<0.01). Using Kaplan-Meier statistics, the risk of acute clustering of seizures ≤7 days was 22%, with a statistical trend for TCOR as a predictive factor (p=0.06). The risk of seizure recurrence associated with worsening/recurrence of stroke beyond 7 days was 13.5% at 2 years, 16.4% at 4 years and 18% at 8 years. Presence of >2 cardiovascular risk factors (p<0.05) and status epilepticus (P<0.05) are predictive risk factors on Cox regression model. The risk of US was 19% at 2 years, 25% at 4 years and 28% at 8 years with epileptiform EEG as a predictive factor (p<0.05).

CONCLUSIONS

Seizure recurrence following AS after ischaemic stroke may appear as acute clustering. Afterwards, seizures may occur as often with a recurrent stroke as without one within 4.2 years. We recommend the use of antiepileptic agents for up to 4 years if the underlying stroke aetiology cannot be fully treated.

Good collateral circulation predicts favorable outcomes in intravenous thrombolysis: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Baseline collateral status has been correlated with outcomes of acute ischaemic stroke patients receiving intravenous thrombolysis (IVT) in previous studies. We carried out the current systematic review and meta-analysis to synthesize currently available evidence regarding such correlations.

METHODS

Full-text articles published since 2000 were retrieved and screened. The overall effect sizes of good versus poor collateral status over a series of outcomes and certain baseline features were estimated by random-effects models and presented in risk ratios (RRs) or mean differences.

RESULTS

Overall, 28 (3057 patients) and 14 (1584 patients) studies were included in qualitative and quantitative synthesis, respectively. Compared with poor pre-treatment collateral status, good collaterals showed a beneficial effect over the primary outcome of a favorable functional outcome at 3 or 6 months [RR, 2.45; 95% confidence interval, 1.94-3.09; P < 0.001] in acute ischaemic stroke patients receiving IVT treatment. However, such an effect tended to be different between studies with prescribed time windows of 3, 4.5 and > 4.5 h (up to 7 h), with the RRs being 2.21, 2.48 and 5.00, respectively (I²  = 53%). Good pre-treatment collaterals were also associated with a smaller infarct size at baseline, and a lower rate of symptomatic intracranial hemorrhage and a higher rate of neurological improvement early after IVT treatment.

CONCLUSIONS

The present study has demonstrated the prognostic value of baseline collateral circulation for outcomes of acute ischaemic stroke patients receiving intravenous reperfusion therapies, studied with different time windows of up to 7 h after ictus for IVT therapy.

Noninvasive Follicular Variant of Papillary Thyroid Carcinoma and the Afirma Gene-Expression Classifier

BACKGROUND

It is now recognized that noninvasive follicular variant of papillary thyroid carcinoma (NFVPTC) is a distinct subset of FVPTC with an exceedingly indolent clinical course. The Afirma gene-expression classifier (GEC) helps guide clinicians in the management of thyroid nodules with indeterminate fine-needle aspiration (FNA) results. Thyroid surgery is recommended for nodules with a suspicious Afirma result, whereas observation is deemed reasonable for most nodules with a benign result. The aim of this study was to confirm that the Afirma test detects NFVPTCs and to determine how many carcinomas detected by the Afirma GEC represent NFVPTCs.

METHODS

From a database of 249 FNAs sent for Afirma testing between January 2012 and October 2014, a search was conducted for cases with a preceding FNA diagnosis of atypia/follicular lesion of undetermined significance (AUS/FLUS) or suspicious for a follicular neoplasm (SFN), a suspicious Afirma result, and a corresponding resection specimen reviewed at Brigham and Women's Hospital. The diagnoses of the prior FNAs and subsequent resection specimens were recorded. Slides for all resection specimens with a diagnosis of FVPTC were reviewed to identify NFVPTCs.

RESULTS

Sixty-three cases met the inclusion criteria. The preceding FNA diagnosis was AUS/FLUS in 34 (54%) cases and SFN in 29 (46%) cases. The surgical resection specimen demonstrated 16 (25%) FVPTCs, five (8%) follicular thyroid carcinomas, one (2%) classical type PTC, and 41 (65%) benign tumors/nodules. Of the 16 FVPTCs, 14 (88%) were NFVPTCs. Thus, NFVPTCs accounted for 64% of the carcinomas in the cohort.

CONCLUSION

These results indicate that the Afirma GEC detects NFVPTCs and that many of the carcinomas detected by Afirma are NFVPTCs. While all care should be individualized and include clinical and sonographic assessment, these results suggest lobectomy as opposed to total thyroidectomy should be considered for nodules with a preceding AUS/FLUS or SFN on cytology and a suspicious Afirma result.

Pontine microbleeds and depression in stroke

OBJECTIVES

Depression is the most common affective disorder following stroke yet the neuroanatomical model of poststroke depression (PSD) remains unclear. This study examined the association between PSD and cerebral microbleeds (CMBs) and hypothesized that CMBs in specific regions would be associated with PSD.

METHODS

Of the 4766 patients with first ever or recurrent acute ischemic stroke admitted to the Acute Stroke Unit of the Prince of Wales Hospital between June 2004 and October 2010, 229 met the entry criteria and formed the study sample. Patients with a Geriatric Depression Scale score of 7 or above were classified as having PSD. The presence and location of CMBs were evaluated with magnetic resonance imaging.

RESULTS

Compared to the non-PSD group, patients with PSD were more likely to have pontine CMBs (32.0% vs 18.2%; P = .019). The presence of pontine CMBs remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 2.2 (P = .016).

CONCLUSION

The results suggest that pontine CMBs are associated with a higher risk of developing PSD.

Location of infarcts and apathy in ischemic stroke

BACKGROUND

Apathy is common in stroke survivors. Unlike poststroke depression, apathy after stroke has not been extensively investigated and the significance of the location of infarcts in the development of apathy following a stroke is unknown. This study examined the association between poststroke apathy (PSA) and the location of infarcts.

METHODS

A cohort of 185 patients with acute ischemic stroke admitted to the Stroke Unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the index stroke, a psychiatrist administered the Apathy Evaluation Scale (AES). PSA was defined as an AES score of 37 or above. The presence and location of infarcts were evaluated with magnetic resonance imaging.

RESULTS

Altogether 185 patients met the entry criteria and formed the study sample; 20 (10.8%) had PSA. PSA patients were older and had higher stroke severity and more depressive symptoms. The PSA group also had lower levels of physical and cognitive functioning. Compared with the non-PSA group, PSA patients were more likely to have acute pontine infarcts (35.0% vs. 11.5%; p = 0.011). They had a higher mean number (0.5 ± 0.7 vs. 0.1 ± 0.3; p = 0.003) and larger volume (0.6 ± 1.4 vs. 0.1 ± 0.3 ml; p = 0.002) of acute pontine infarcts. Six variables were entered into the predictive regression model: age, the presence, number and volume of acute pontine infarcts, the number of old infarcts and periventricular white matter hyperintensities scores. The volume of infarcts remained an independent predictor of PSA in the multivariate analysis, with an odds ratio of 3.9 (p = 0.007). The Geriatric Depression Scale, National Institutes of Health Stroke Scale, Barthel Index and Mini-Mental State Examination scores were also entered into the subsequent associative regression model; the volume of acute pontine infarcts remained a significant predictor (odds ratio = 3.8).

CONCLUSIONS

This is the first report of an association between pontine infarcts and the risk of PSA. The results suggest that pontine infarcts may play a role in the development of PSA. The importance of acute pontine infarcts in the pathogenesis of PSA warrants further investigation.

Serotonin receptor 2C gene polymorphism associated with post-stroke depression in Chinese patients

The serotonin receptor 2C (HTR2C) gene has been shown to play a pivotal role in major depression. We examined the association between post-stroke depression (PSD) and polymorphism in HTR2C. A cohort of 223 patients with acute lacunar stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the onset of the index stroke, a research assistant administered the locally validated 15-item Geriatric Depression Scale. PSD was defined as a geriatric depression scale score of 7 or above. Possible confounding factors, including previous history of stroke, severity of stroke, level of social support, and recent life events, were investigated. All patients were genotyped for polymorphisms of HTR2C. Separate analyses were performed for males and females. Sixty-one patients were found to have PSD. There were significant associations between the HTR2C gene and PSD status in the male patients, but not in the female ones. After adjusting for possible confounders, the rs12837651 T allele (odds ratio = 4.020) and the rs2192371 G allele (odds ratio = 2.866) were found to be significantly associated with PSD in males. Genetic variation in HTR2C receptors appears to be involved in the pathogenesis of PSD in Chinese males.

Poststroke fatigue is associated with caudate infarcts

OBJECTIVE

The caudate nucleus may be involved in the pathogenesis of the fatigue observed in neurological disorders. However, the significance of caudate lesions in poststroke fatigue (PSF) is unknown. This study examined the association between caudate infarcts and PSF.

METHODS

Five hundred Chinese patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong participated in the study. All participants were assessed for PSF with the Fatigue Severity Scale (FSS) three months after their index stroke. PSF was defined as a mean FSS score of 4.0 or more. Physical functioning and depressive symptoms were measured by the Barthel Index (BI) and the Geriatric Depression Scale (GDS).

RESULTS

One hundred and twenty-five (25.0%) of the patients had PSF. Compared to the non-fatigue group, the PSF patients were more likely to be women and had hyperlipidemia, lower BI and higher GDS scores. Caudate (8.0% versus 1.3%, p=0.001) and putamen (19.2% versus 12.0%, p=0.043) acute infarcts were more common in the PSF group, whereas pons infarcts (13.6% versus 22.2%, p=0.038) were less common. Acute caudate infarcts remained an independent predictor of PSF in the multivariate analysis, with an odds ratio of 6.4.

CONCLUSIONS

The results suggest that patients with PSF are more likely to have caudate infarcts.

Autonomic dysfunction in ischemic stroke with carotid stenosis

OBJECTIVES

Impaired autonomic function is common in acute ischemic stroke. Previous limited studies have suggested that atherosclerosis may affect the distensibility of the carotid sinus and then impair the cardiovascular autonomic function. This study sought to investigate cardiovascular autonomic function in patients with ischemic stroke with carotid stenosis.

METHODS

Eighty-five patients with ischemic stroke (58 ones without carotid stenosis and 27 ones with carotid stenosis, average 6 months after stroke onset) and 37 elderly controls were recruited. All performed Ewing's battery autonomic function tests.

RESULTS

From Ewing's battery of autonomic function tests, atypical, definite, or severe autonomic dysfunction was identified in 69.0% patients without carotid stenosis and 88.9% with carotid stenosis, with significant difference between the two groups, and the prevalence of autonomic dysfunction in both groups was higher than that in controls (21.6%). Patients with carotid stenosis showed impairment of all parasympathetic tests (all P < 0.05) and one of the sympathetic tests [Mean fall in systolic blood pressure (BP) on standing: P = 0.051], and those without carotid stenosis only showed impairment in two parasympathetic tests (Valsalva ratio: P = 0.014; heart rate response to deep breathing: P < 0.001) in comparison with controls. Patients with carotid stenosis had significantly more impairment than those without carotid stenosis in some autonomic parameters (Valsalva ratio: P < 0.05; mean fall in systolic BP on standing: P < 0.05).

CONCLUSIONS

Cardiovascular autonomic function is impaired in patients with ischemic stroke, but patients with carotid stenosis show more severely impaired parasympathetic and sympathetic functions.

Predictors of the depressive symptomatology of the family caregivers of Chinese stroke patients in Hong Kong

The aim of this cross-sectional study was to determine the socio-demographic and clinical factors associated with depressive symptoms in the family caregivers of Hong Kong Chinese stroke patients. One hundred and twenty-three patients at a stroke clinic and their family caregivers formed the study sample. The depressive symptoms of both the patients and their family caregivers were rated with the Chinese version of the 15-item Geriatric Depression Scale (GDS). Participants' socio-demographic data and clinical characteristics served as the independent variables in relation to the caregivers' GDS scores. Patients' and caregivers' somatic and psychological conditions were measured with 10 scales. In univariate analysis, caregivers' GDS scores were significantly correlated with certain of their characteristics [Modified Life Event Scale (MLES), Cumulative Illness Rating Scale (CIRS) and Lubben Social Network Scale (LSNS) scores, sex and being a housewife] and those of the patients (GDS score and being a housewife). Multiple regression analysis showed caregivers' MLES and CIRS scores and patients' GDS scores to be independent correlates of caregivers' GDS scores. Adverse events encountered by caregivers in the past 6 months, their current health problems and patients' depressive symptoms were found to be the principal factors associated with caregivers' depressive symptoms.

Intracranial electroencephalogram to evaluate refractory temporal and frontal lobe epilepsy

OBJECTIVE

We undertook a collaborative study in a multidisciplinary team to channel refractory epilepsy patients to test a hypothesis about placement of intracranial electroencephalography arrays.

DESIGN

This was a descriptive case series. Prospective non-invasive presurgical evaluations were based on clinical semiology, magnetic resonance imaging, video-electroencephalography findings and neuropsychological assessments. If the results were discordant, a hypothesis was generated using individualised combinations of positron emission tomography, single-photon emission computed tomography, functional magnetic resonance imaging and Wada tests. The indications for intracranial electroencephalography were: (a) focal magnetic resonance imaging, ictal/interictal scalp electroencephalography with variable results (group A); (b) multi-focal magnetic resonance imaging, focal/multi-focal ictal scalp electroencephalography (group B); (c) non-lesional magnetic resonance imaging, focal/multi-focal ictal scalp electroencephalography (group C). We evaluated whether the seizure-onset zones and eloquent areas were delineated, surgical outcomes (if operated on), and pathology results.

SETTING

A tertiary referral centre for neurology in Hong Kong.

PATIENTS

A total of 105 refractory epilepsy patients completed non-invasive presurgical evaluations over the period 2007 to 2009. Thirty-two patients were eligible for direct resective surgery, and another 25 patients had a testing hypothesis formulated. Of these 25 patients, 10 were eligible for intracranial electroencephalography based on technical/financial considerations.

RESULTS

All 10 patients (group A=2, group B=4, group C=4) had their epileptogenic zones defined. Six patients underwent functional mapping, all of whom had their eloquent areas defined. Seven of the 10 patients underwent resective surgery; four of them achieved Engel class I/II outcomes. The dichotomised outcomes were 100% (group A), 50% (group B), and 33% (group C) achieving Engel class I/II. Two patients had asymptomatic subdural haematoma. There was no intracranial infection or operative mortality. In five (71%) of seven of the patients, a histological diagnosis was established.

CONCLUSION

Proper deployment of intracranial electroencephalography is useful in the presurgical evaluation of patients with refractory epilepsy. This modality of management is potentially of benefit for patients with refractory epilepsy, but is underutilised locally.

ACE gene sequence and nucleotide variants in IgA nephropathy

INTRODUCTION

Association studies with single nucleotide polymorphisms (SNPs) have been contradictory. Haplotypes may be more helpful. With gene sequencing, all SNPs can be found for construction of haplotypes.

METHODS

The ACE gene was sequenced in four healthy Chinese subjects and 20 patients with IgA nephropathy (IgAN) to observe if differences exist among SNPs and haplotypes. 20 patients on angiotensin 1-converting enzyme inhibitor/angiotensin receptor antagonist (ACEI/ATRA) therapy were then compared with another 20 patients not treated with ACEI /ATRA to determine their renal outcome in response to ACEI/ATRA therapy and whether their genetic profile of ACE gene could play a role in determining their outcome to ACEI /ATRA therapy and progression to end-stage renal failure (ESRF).

RESULTS

IgAN patients had 53 variants, of which 17 were unique, whereas normal subjects had 38 variants, of which two were unique (p less than 0.005). No unique variant was a significant risk factor for IgAN. Significant genotype and allele frequency differences in five variants were observed between IgAN patients with renal impairment and those with ESRF (p less than 0.02).

CONCLUSION

Our data suggests that at least in the ACE gene, haplotyping SNPs within a single gene seems to have no added advantage over genotyping the individual component SNPs. The D allele and haplotype 3 confer an adverse prognosis, while the I allele and haplotype 5 appear to be renoprotective. The data suggests that genotypes of the ACE gene are linked to certain haplotypes, which could influence IgAN patients' response to ACEI/ATRA therapy.

Cerebral microbleeds and depression in lacunar stroke

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMB) are common in stroke survivors and the community-dwelling elderly. The clinical significance of CMB in the development of depression after a stroke is unknown. This study examined the association between poststroke depression (PSD) and CMB.

METHODS

A cohort of 235 patients with acute lacunar stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the onset of the index stroke, a research assistant administered the locally validated 15-item Geriatric Depression Scale. PSD was defined as a Genetic Depression Scale score of ≥7. The presence and location of CMB were evaluated with MRI.

RESULTS

In comparison with the non-PSD group, PSD patients were more likely to have lobar CMB (33.3% versus 19.9%; P=0.022). Lobar CMB remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 2.08 (P=0.032).

CONCLUSIONS

The results suggest that lobar CMB may play a role in the development of PSD. The importance of CMB in the pathogenesis of depression in stroke survivors and the general elderly population warrants further investigation.

Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) of urinary protein in acute kidney injury

Recent experimental and clinical studies have shown the importance of urinary proteomics in acute kidney injury (AKI). We analyzed the protein in urine of patients with clinical AKI using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) for its diagnostic value, and followed them up for 40 months to evaluate prognosis. Urine from 31 consecutive cases of AKI was analyzed with SDS-PAGE to determine the low, middle and high molecular weight proteins. Fractional excretion of sodium (FENa) was estimated from serum and urine creatinine and sodium (Na). The cases were followed-up for 40 months from the end of the recruitment of study cases. Glomerular protein was higher in the hematuria group when compared with the non-hematuria group (P <0.04) and in the AKI group than in the acute on chronic renal failure (AKI-on-CRF) group (P <0.002). Tubular protein was higher in the AKI-on-CRF group (P <0.003) than in the AKI group. Tubular protein correlated with FENa in groups with diabetes mellitus (DM), AKI-on-CRF, and without hematuria (P <0.03, P <0.02 and P <0.004, respectively). Pattern of protein did not differ between groups with and without DM and clinical acute tubular necrosis (ATN). At the end of 40 months follow-up, category with predominantly glomerular protein progressed to chronic renal failure (CRF) or end-stage renal failure in higher proportion (P <0.05). In clinical AKI, we observed that glomerular protein dominated in cases with glomerular insult, as indicated by hematuria. Tubular protein was common in the study cases with CRF, DM and cases without hematuria. This indicates tubulo-interstitial injury for AKI in these cases. Patients with predominantly glomerular protein had an adverse outcome.

Cerebral microbleeds and symptom severity of post-stroke depression: a magnetic resonance imaging study

BACKGROUND

Cerebral microbleeds (CMBs) are common in stroke survivors, although their clinical significance in the development of psychiatric conditions following stroke remains unknown. This study examines the association between post-stroke depression (PSD) symptom severity and CMBs.

METHODS

Amongst the 4088 patients with acute ischemic stroke who had been admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong, between December 2004 and May 2009, 994 patients were recruited. A psychiatrist administered the Structural Clinical Interview for DSM-IV to all 994 patients and made a diagnosis of PSD three months after the index stroke. PSD symptom severity was assessed with the 15-item Geriatric Depression Scale (GDS). Seventy-eight patients were found to have PSD. The presence and location of CMBs were evaluated with magnetic resonance imaging (MRI).

RESULTS

Seventy-eight patients (7.8%) had PSD. CMBs were identified in 20 PSD patients. Relative to the no-CMB group, the mean GDS score of patients with lobar CMBs was significantly higher (12.6±2.6 versus 10.4±2.5, p=0.01 after adjusting for age, sex, global cognitive functions, neurological deficits and white matter hyperintensities).

LIMITATIONS

Patients with more severe stroke, those who died before the three-month follow-up and those who became depressed later were excluded, as were those unable to give their consent due to dementia or aphasia. These selection biases may limit the generalizability of the findings.

CONCLUSIONS

The results suggest that lobar CMBs may contribute to PSD symptom severity. The importance of CMBs in the pathogenesis of other psychiatric disorders in stroke survivors and other patient populations warrants further investigation.

Impact of patterns of proteinuria on renal allograft function and survival: a prospective cohort study

BACKGROUND

Proteinuria is an important complication in renal transplant recipients. The aim of this prospective study was to evaluate the long-term impact of transplant proteinuria patterns on allograft function and survival.

METHODS

We analyzed urinary protein of a cohort of 83 renal transplants with proteinuria ≥0.5 g/d by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and radial immunogel diffusion assay. After initial stratification and analysis, the cohort was followed up for 16 yr. The graft outcome and survival were analyzed using Cox regression model to determine their association with different patterns of initial transplant proteinuria.

RESULTS

Group with predominantly glomerular (middle- and high-molecular-weight with or without low-molecular-weight) proteinuria (61%) had higher serum creatinine (p < 0.001) than the group with predominantly tubular (low-molecular-weight) proteinuria (39%). The incidences of chronic graft dysfunction and graft loss had increased in the glomerular proteinuria group (p < 0.001, hazard ratio 3.6, 95% confidence interval 1.7-7.5 and p < 0.001, hazard ratio 4.9, 95% confidence interval 1.9-12.1, respectively). Patient death did not differ (p = 0.434, hazard ratio 1.5, 95% confidence interval 0.5-4.5).

CONCLUSION

  Proteinuria in renal transplants can be differentiated into glomerular and tubular types based on molecular weight. Glomerular proteinuria is associated with significant increase in graft dysfunction and graft loss.

Operational definitions improve reliability of the age-related white matter changes scale

BACKGROUND AND PURPOSE

Although the age-related white matter changes (ARWMC) scale has been advocated to be applicable to both MRI and CT for assessing the severity of WMC, its inter-rater reliability on CT is only fair. We aimed to operationalize the ARWMC scale and investigate the effect of this operationalization on the reliability and validity on MRI and CT.

METHODS

Operational definitions of the ARWMC scale were derived from Erkinjuntti research criteria for subcortical vascular dementia and Scheltens scale. Using original and operationalized ARWMC scale, eight observers recorded the time for rating per MRI and per CT. We investigated the inter-rater and intrarater reliability as well as validity against volume using data from 97 stroke patients.

RESULTS

Inter-rater reliability of the operationalized scale on CT (0.874, 95% confidence interval [0.780-0.934]) was better than the original scale (0.569, 95% confidence interval [0.247-0.775]). Its intrarater reliability on CT (0.869) and reliability on MRI (inter-rater: 0.860; intrarater: 0.838) was comparable with the original scale (CT intrarater: 0.750 and on MRI inter-rater: 0.845; intrarater: 0.853). The time required to administer the operationalized scale (4'2″ for MRI and 1'18″ for CT) was similar to that of the original scale (3'56″ for MRI and 1'16″ for CT). The original scale and operationalized scale also significantly correlated with WMC volume (operationalized scale ρ = 0.613, P < 0.001, original scale ρ = 0.638, P < 0.001).

CONCLUSION

Operational definitions improve the inter-rater reliability of ARWMC scale on CT, and it correlates with volumetric measurement.

White matter hyperintensities in post-stroke depression: a case control study

OBJECTIVE

Despite extensive research on post-stroke depression (PSD), the role of white matter hyperintensities (WMHs) in its pathogenesis remains uncertain. The aim of this study was to evaluate the relationship between WMHs and PSD in Chinese patients with first or recurrent stroke.

METHODS

A cohort of 994 patients with acute ischaemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. A psychiatrist administered the Structural Clinical Interview for DSM-IV to all patients and made a diagnosis of PSD 3 months after the index stroke. 78 (7.8%) patients had PSD; 78 stroke patients matched according to age and sex but without PSD served as a control group. The severity and location of WMHs were evaluated with MRI.

RESULTS

In comparison with the non-PSD group, patients in the PSD group were more likely to have severe deep WMHs (12.8% vs 1.3%; p=0.009). Severe deep WMHs remained an independent predictor of PSD in the multivariate analysis with an OR of 13.8 (p=0.016).

CONCLUSION

The results suggest that WMHs may play a role in the development of PSD. The importance of WMHs in the treatment and outcome of PSD warrants further investigation.

Genetic polymorphisms of Chinese patients with ischemic stroke and concurrent stenoses of extracranial and intracranial vessels

The etiology of concurrent stenoses of extracranial and intracranial vessels in patients with ischemic stroke is poorly understood, but hereditary factors are believed to be important. We aimed to determine whether genetic polymorphisms affecting homocysteine and lipid metabolism are associated with concurrent stenoses. The genotypes of 191 Han Chinese patients with acute ischemic stroke, of whom 47 (25%) had concurrent stenoses, and 167 healthy control patients in Hong Kong were examined for the following polymorphisms: paraoxonase 1 (PON1) Q192R, methylenetetrahydrofolate reductase (MTHFR) A222V, glutamate-cysteine ligase catalytic-subunit (GCLC)-129C>T, and oxidized low-density lipoprotein receptor (OLR) 3' untranslated region C>T (rs1050283). The genotype distributions of PON1 Q192R and MTHFR A222V, which affect lipid and homocysteine metabolism, differed significantly between patients with stroke and healthy controls. The presence of at least one R allele in PON1 Q192R and a TT allele in OLR rs1050283 were associated with concurrent stenoses. We also identified a possible association between the presence of at least one V allele in MTHFR A222V and concurrent stenoses. This study shows that genetic polymorphisms affecting homocysteine and lipid metabolism are possible risk factors for stroke and concurrent stenoses.

Microbleeds and post-stroke emotional lability

OBJECTIVE

The clinical significance of microbleeds (MBs) in the development of psychiatric conditions following a stroke is unknown. Lesions located in various cortical and subcortical areas are thought to be involved in the pathophysiology of post-stroke emotional lability (PSEL). This study examined the association between PSEL and MBs.

METHODS

A total of 519 Chinese patients with acute ischaemic stroke consecutively admitted to the acute stroke unit of a university affiliated regional hospital in Hong Kong were screened for PSEL 3 months after their index stroke. The number and location of MBs were evaluated with MRI.

RESULTS

According to Kim's criteria, 74 (14.3%) patients had PSEL. In comparison with the non-PSEL group, patients in the PSEL group were more likely to have MBs in the thalamus as a whole (16.2% vs 6.5%; p = 0.004), its anterior (6.9% vs 2.0%, p = 0.02) and paramedian territories (8.1% vs 3.1%; p = 0.04), and a higher number of MBs in the entire brain (1.7+3.4 vs 1.3+5.0; p = 0.031). MBs in the thalamus remained an independent predictor of PSEL in the multivariate analysis, with an odds ratio of 4.7 (p = 0.002).

CONCLUSION

Our results suggest that MBs in the thalamus may play a role in the development of PSEL. The importance of MBs in PSEL and other psychiatric conditions in stroke survivors warrants further investigation.

Use of magnetic resonance angiography to predict long-term outcomes of ischemic stroke patients with concurrent stenoses in Hong Kong

PURPOSE

To determine the long-term outcome of ischemic stroke patients with concurrent intracranial and extracranial atherosclerosis using magnetic resonance angiography.

METHODS

A prospective cohort of patients in Hong Kong with acute ischemic stroke was studied with magnetic resonance angiography of the brain and carotid duplex. All patients were followed up regularly for the development of recurrent stroke, cardiac events, or death.

RESULTS

Totally 343 patients with acute ischemic stroke were included, of whom 104 (30%) had concurrent intracranial and extracranial lesions. The follow-up period was up to 76 months (mean 44.5 months). Overall, 55 patients (15.5%) died of any cause and 91 patients (26.5%) suffered a further nonfatal vascular event. The overall 5-year cumulative rates of mortality, restroke and poor outcomes (combined death and further vascular events) were 18, 27 and 37%, respectively. In patients with concurrent lesions, these rates were 31, 41 and 51%, respectively. The corresponding rates were 13, 22 and 31% in patients without concurrent lesions. The risks were highest in the first year after stroke. More deaths (log rank, 16.3; p = 0.0001), restrokes (log rank, 9.71; p = 0.002) and poor outcomes (log rank, 13.87; p = 0.0001) were found among patients with concurrent lesions. The presence of concurrent vascular lesions, advanced age, smoking, hyperlipidemia and previous history of stroke were independent predictors of poor outcomes.

CONCLUSIONS

The long-term prognosis of ischemic stroke patients with concurrent atherosclerosis of intracranial and extracranial vessels is poor. They are at high risk of further vascular events or death.

Hand-assisted laparoscopic colectomy versus standard laparoscopic colectomy: a cost analysis

OBJECTIVE

There is a relative dearth of literature comparing hand-assisted (HALC) to standard (SLC) laparoscopic colectomies. HALC seems beneficial in terms of shorter operative times and lower conversion rates, but this is counterbalanced by a greater inflammatory response, larger incisions and higher direct costs. Nevertheless, these results are not consistent throughout existing studies and there are to date no detailed cost comparisons. Our hypothesis was that HALC would not incur significantly higher institutional costs compared with standard laparoscopic techniques.

METHOD

Patients undergoing either SLC or HALC between August 2004 and September 2006 were retrospectively reviewed. All patients were managed using a standard protocol. Outcomes assessed included operative times, conversion rates, pain scores, time to resolution of ileus, length of stay and complications. Total costs were calculated from the day of surgery. Statistical analyses included chi(2), Fisher's exact test, the Mann-Whitney U-test or nonparametric bootstrapping method.

RESULTS

Seventy-three patients underwent SLC while 101 had HALC. Demographics and indications for surgery in both groups were similar; the majority were performed for colorectal cancers. Operative times were shorter (147.5 vs 172.5 min, P < 0.05) and complication rates lower (28.7%vs 45.2%, P < 0.025) for HALC. There was no significant difference in the other clinical outcomes. Operative costs and cost of consumables were higher for HALC (US$4024.2 vs US$3568.1, P = 0.01 and US$1724.7 vs US$1302.7, P < 0.001, respectively). However, total costs were not significantly different (HALC US$8999.8, SLC US$7910.7, P = 0.11).

CONCLUSION

Institutional costs are not significantly higher for HALC compared with SLC.