What Therapeutic Biomarkers in Gastro-Esophageal Junction and Gastric Cancer Should a Pathologist Know About?

Malignancies of upper gastrointestinal tract are aggressive, and most locally advanced unresectable and metastatic cancers are managed by a combination of surgery and neoadjuvant/adjuvant chemotherapy and radiotherapy. Current therapeutic recommendations include targeted therapies based on biomarker expression of an individual tumor. All G/gastro-esophageal junction (GEJ) cancers should be tested for HER2 status as a reflex test at the time of diagnosis. Currently, testing for PDL 1 and mismatch repair protein status is optional. HER2 testing is restricted to adenocarcinomas only and endoscopic biopsies, resections, or cellblocks. Facilities should be available for performing validated immunohistochemical stains and in-situ hybridization techniques, and importantly, pathologists should be experienced with preanalytical and analytical issues and scoring criteria. Genomic profiling via next-generation sequencing (NGS) is another strategy that assess numerous mutations and other molecular events simultaneously, including HER2 amplification, MSS status, tumor mutation burden, and neurotrophic tropomyosin-receptor kinases gene fusions.

Rethinking Low-Risk Papillary Thyroid Cancers < 1cm (Papillary Microcarcinomas): An Evidence Review for Recalibrating Diagnostic Thresholds and/or Alternative Labels

Background: Recalibrating diagnostic thresholds or using alternative labels may mitigate overdiagnosis and overtreatment of papillary microcarcinoma (mPTC). We aimed at identifying and collating relevant epidemiological evidence on mPTC, to assess the case for recalibration and/or new labels. Methods: We searched EMBASE and PubMed databases from inception to December 2020 for natural history, autopsy, diagnostic drift, and diagnostic reproducibility studies. Where a relevant systematic review was pre-identified, only new articles were additionally included. Non-English articles were excluded. One author screened titles and abstracts. Two authors screened full text articles, performed quality assessments, and extracted data. We undertook narrative synthesis of included evidence (pooled estimates from systematic reviews and single estimates from primary studies). Results: One systematic review of patients undergoing active surveillance found that after 5 years of follow-up, 5.3% (95% confidence interval [CI 4.4-6.4%]) of the mPTC lesions had increased in size by ≥3 mm, and 1.6% [CI 1.1-2.4%] of patients had lymph node metastases. Among 7 new primary studies (including 3 updates on 2 studies included in the systematic review), 1-5% of patients undergoing active surveillance had lymph node metastases after a median follow-up of 1-10 years. One systematic review found that subclinical thyroid cancer incidentally discovered at autopsy is relatively common, with a pooled prevalence of 11.2% [CI 6.7-16.1%] among studies that examined the whole thyroid. Four diagnostic drift studies evaluated the new classification of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Three studies of cases previously diagnosed as papillary thyroid cancer found 1.3-2.3% were reclassified as NIFTP (reclassifications were from follicular variation of papillary thyroid cancer [FVPTC]). One study of 48 cases previously diagnosed as mPTC found that 23.5% were reclassified as NIFTP. Thirteen reproducibility studies of papillary thyroid lesions found substantial variation in the histopathological diagnosis of thyroid lesions, including FVPTC and NIFTP classifications (no study evaluated mPTC). Conclusions: This review supports consideration of recalibrating diagnostic thresholds and/or alternative labels for low-risk mPTC.

A survival guide to HER2 testing in gastric/gastroesophageal junction carcinoma

Human epidermal growth factor receptor 2 (HER2) status determines gastric/gastroesophageal junction (GEJ) adenocarcinomas that benefit from targeted therapy; hence, HER2 testing has become a routine practice. Accurate HER2 testing is fundamental to select eligible patients who will benefit from HER2-targeted treatment. The reported HER2-positive rate in gastric/GEJ cancers ranges from 4.4% to 53.4%, and HER2-positive tumors are considered to have more-aggressive biologic behavior and tumor recurrence. Main modalities of HER2 testing in clinical practice include immunohistochemistry (IHC) for protein expression and in situ hybridization (ISH) for gene amplification. Many technical pitfalls affect the accuracy of HER2 result. Additionally, several issues in HER2 testing are related to the tumor biology, sample selection, interpretation of IHC and ISH results, and confirming HER2 status. Therefore, gastric/GEJ adenocarcinoma-specific HER2 testing protocols have been developed and standardized to minimize the impact of these preanalytical and analytical factors and to enhance reproducibility of HER2 testing results. This review provides up-to-date practical guidance to clinicians on accurate HER2 testing and interpretation of results in gastric/GEJ adenocarcinoma.

Granulomas in the gastrointestinal tract: deciphering the Pandora's box

Granulomas are organised collection of activated histiocytes induced by a persistent antigen stimulus. A wide variety of antigens encountered by the gastrointestinal tract are of this nature and hence the resulting granulomatous inflammation represents a tissue reaction pattern. The potential causes can be broadly classified as infections or non-infectious immune reactions. There is also a group where a cause is never identified. Granulomas may be of varying morphological appearance, most commonly epithelioid, foreign body type, suppurative and necrotizing. This may provide a clue as to the aetiology; however, in most cases, the cause requires further inquiry. Pathologists may need to cut deeper levels to look for foreign material and apply special stains to look for microorganisms. Pathologists also need to be certain that the process is a true granuloma and not a mimic. The site of occurrence in the gastrointestinal tract and the clinical setting is often paramount in establishing the aetiology. For instance, infections are more likely the cause in developing countries or when there is immunosuppression. Similarly, granulomas in the stomach are usually due to Crohn's disease; however, it is only rarely the cause of granulomas isolated to the appendix.

Chief cell-predominant gastric polyps: a series of 12 cases with literature review

AIMS

Rare gastric lesions composed of a combined proliferation of chief and oxyntic cells have been variably called adenocarcinoma of fundic gland type and oxyntic gland polyp/adenoma. Herein, we present a series of cases that show a morphological spectrum of chief and oxyntic cell proliferations.

METHODS AND RESULTS

Routine and consultation cases were collated from five institutions. Information regarding site, size, endoscopic appearance, clinical history and medication use, when available, was accrued, as was the histological features and immunoprofiles. A total of 12 cases were collated. Age ranged from 39 to 81 years. All the lesions were located in the fundus; seven of eight were polypoid lesions endoscopically. Lesions were primarily solitary, averaged 4.6 mm in diameter (largest 9 mm) and comprised >50% chief cells. The predominant architectural pattern was of anastomosing and solid and clustered glands or a mixture of these patterns. Lesions were limited mainly to the mucosa, although two showed submucosal involvement. None had known metastatic disease.

CONCLUSIONS

This series included lesions that were previously described as gastric adenocarcinoma of fundic gland type and oxyntic gland polyp/adenoma. They are located exclusively in the fundus and composed predominantly of chief cells with low-grade cytology and appear to show a morphological continuum.

Gastric HER2 Testing Study (GaTHER): an evaluation of gastric/gastroesophageal junction cancer testing accuracy in Australia

Trastuzumab provides a survival benefit in patients with human epidermal growth factor receptor 2 (HER2)-amplified/overexpressed advanced gastric and gastroesophageal junction cancers (GC/GJCs). However, the optimal method for testing is unclear. The aim of this study was to assess interlaboratory agreement on HER2 scoring in GC/GJC to aid the development of a robust testing algorithm for diagnostic practice in Australia. Nine laboratories assessed the HER2 status of 100 GC/GJC tissue samples by immunohistochemistry (IHC) and in situ hybridization (ISH) [chromogenic (CISH) or silver (SISH)] using both HER2 copy number and HER2:chr17 (chromosome 17) ratio. Results were compared with reference fluorescence ISH (FISH). Interlaboratory agreement on IHC3+ scoring was good (κ=0.76), and there was good/very good agreement between IHC (positivity defined as IHC3+) and ISH when HER2 copy number was used (κ=0.72 to 0.87). Agreement on CISH/SISH scoring was good/very good when HER2 copy number was used (κ=0.68 to 0.86), and agreement between CISH/SISH and FISH using HER2 copy number was very good (κ=0.88 to 0.91). Agreement was reduced when HER2:chr17 ratio was used. The good agreement for HER2 copy number determined by bright-field ISH suggests that this is the optimal method for testing in GC/GJC cases. An IHC3+ score was strongly predictive of a positive ISH result, although agreement for all IHC scores was only moderate, suggesting that IHC triage before ISH testing would be the most cost-effective strategy. However, because of the unique features of GC/GJC samples and the difficulty of ensuring consistent HER2 staining in the community setting, it is recommended that HER2 status in advanced GC/GJC be determined by both IHC and ISH in the same laboratory.

Human epidermal growth factor receptor 2 testing in gastric carcinoma: issues related to heterogeneity in biopsies and resections

AIMS

To assess human epidermal growth factor receptor 2 (HER2) status and heterogeneity using immunohistochemistry (IHC) and silver in-situ hybridization (SISH) in gastric carcinoma and dysplasia, and to correlate HER2 status between biopsy and resection specimens of gastric carcinoma.

METHODS AND RESULTS

Immunohistochemistry for HER2 was performed in 178 cases of gastric carcinoma, and SISH in cases showing at least 1+ reaction. HER2 positivity [European Medicines Agency (EMA) guidelines] was identified in 20.2% of carcinomas and 12.9% of high-grade dysplasia, and HER2 heterogeneity noted in 50% and 33% of these cases, respectively. IHC negative/positive reactivity and SISH results were concordant in 96.2%. SISH amplification was seen in 35.3% of IHC 2+ and in a case with previously unrecognized staining pattern. Concordance of IHC HER2 status on biopsies and gastrectomies was seen in 74.1%. False negative IHC results on either the biopsy or gastrectomy were seen in 19.4% of HER2 amplified cases.

CONCLUSIONS

Human epidermal growth factor receptor 2 status in gastric carcinoma is comparable to previous studies with good concordance between IHC and SISH; all IHC 2+ and unusual patterns should be assessed with ISH studies; heterogeneity of tumour HER2 overexpression/amplification is common with possible implications for HER2 testing; and HER2 overexpression appears sufficiently specific to be considered a potential diagnostic biomarker of dysplasia.

Duodenal adenocarcinoma arising from a pyloric gland adenoma with a brief review of the literature

Pyloric gland-type adenoma of the duodenum with documented malignant progression is rare. A case is presented of an 87-year-old man with bloating and nausea, who on investigation was found to have a polyp on the anteroinferior wall of the duodenal cap. Histologic examination of the polyp showed features of a pyloric gland adenoma (PGA) demonstrating the full spectrum of progression from low- to high-grade dysplasia and finally invasive adenocarcinoma. The carcinoma showed gastric-type differentiation highlighted by its mucin immunohistochemistry profile and was of advanced stage with lymph node metastasis. The literature on PGAs and the little documentations on progression to carcinoma in duodenal PGAs are reviewed.

DNA mismatch repair enzyme immunohistochemistry in colorectal cancer: a comparison of biopsy and resection material

BACKGROUND

Microsatellite instability (MSI) in colorectal cancer (CRC) may be predicted using mismatch repair protein (MMRP) immunohistochemistry (immunostaining), allowing focused genetic investigations and potentially influencing therapeutic interventions. Most laboratories perform immunostaining on surgical resection specimens. Endoscopic biopsy specimens are an alternative tissue source for immunostaining. Given the sensitivity of immunostaining to the degree of tissue fixation, endoscopic biopsy material may produce superior staining, based on faster and more thorough fixation. Moreover, in patients receiving neoadjuvant chemotherapy and/or radiotherapy, endoscopic biopsies may be more useful than surgical resection specimens by allowing assessment of MMR status prior to chemotherapy and/or radiotherapy induced changes in tumours. This study examines whether immunostaining for MMRP expression in CRC is as reliable on endoscopic biopsy material as on surgical resection specimens.

METHODS

Immunostaining for MLH1, PMS2, MSH2 and MHS6 was performed on 112 unselected CRC cases with both endoscopic biopsy and surgical resection material available. A single observer blindly examined intensity and distribution of staining and assessed MMRP expression. Two consultant histopathologists reviewed challenging cases. Endoscopic biopsies and surgical resections were compared using non-parametric statistical analysis.

RESULTS

Immunostaining for all four MMRPs on all 112 cases produced conclusive (i.e., fully interpretable) results in endoscopic biopsies. In surgical resection specimens, 10 stains from nine cases were inconclusive (stains for two MMRPs were inconclusive in one case). In cases where conclusive immunostaining was achieved, there was complete agreement in MMRP status between the endoscopic biopsy and corresponding surgical resection specimens. Overall, MMRP loss was identified in 13% of cases; 11% MLH1, 12% PMS2, 1% MSH2, and 1% MSH6. Immunostaining intensity was significantly higher (p < 0.0005) and the distribution of staining was significantly more uniform (p < 0.0005) on endoscopic biopsy than on surgical resection.

CONCLUSION

Endoscopic biopsy provides equal accuracy and easier interpretation of MMRP expression immunostaining compared to surgical resection specimens.

Endoscopic biopsy features and diagnostic challenges of adult Crohn's disease at initial presentation

AIMS

Endoscopic biopsy diagnosis of Crohn's disease (CD) is problematic due to lack of specific microscopic features and patchy involvement. There is no documentation of the pattern and severity of microscopic features of CD at initial presentation in adults or children. We aimed to assess the initial mucosal biopsy features of CD in adults and to identify any specific features to confirm the diagnosis.

METHODS

Thirty sets of initial, adult endoscopic biopsies suspected to be CD with subsequent resections, repeat biopsies with long-term follow-up, and/or other confirmatory laboratory results were analysed by three gastrointestinal pathologists, blinded for the final diagnosis for mucosal architectural changes, epithelial abnormalities, chronic and active inflammation and changes of muscularis mucosae and submucosa. There were 25 cases of CD and five cases of non-CD for comparison (3 tuberculosis and 2 right-sided diverticular disease and associated colitis). Cases confirmed as ulcerative colitis were excluded, as diagnostic challenges are already well established.

RESULTS

The majority of initial biopsies (96%) of CD were abnormal with active chronic ileocolitis with a very high proportion (80%) showing the classic combination of abnormal mucosal architecture, epithelial abnormalities and active chronic inflammation. The most sensitive feature was lamina proprial chronic inflammation (sensitivity 92.7%). Sensitivity for other features was as follows: active inflammation 87.8%, basal plasmacytosis 82.1%, architectural changes 80.5% and epithelial abnormalities 70.7%. Abnormalities were found in 94% of ileal and 76% of colonic biopsies. No feature was specific as all tuberculosis and diverticular disease cases showed the classic combination. Granulomata were seen in 10 of 41 CD, in all five tuberculosis and in no diverticular disease biopsies. Small, tight, well defined granulomata characterised CD over large coalesced ganulomata of tuberculosis. Paneth cell and pseudopyloric metaplasia was seen only in CD (2/25).

CONCLUSIONS

Initial endoscopic biopsies of adult CD are significantly abnormal and a majority shows active chronic ileocolitis. The features are sufficiently important to suspect CD at initial presentation in the appropriate clinical setting. Tuberculosis and diverticular disease associated colitis are two important mimics to consider in addition to ulcerative colitis.

Modulation of Iron-Regulatory Genes in Human Hepatocellular Carcinoma and Its Physiological Consequences

Hepatocellular carcinoma (HCC) commonly develops in patients with underlying chronic liver disease. Additionally, the tumorous lesions of HCC patients are consistently characterized by the lack of iron accumulation even when arising in iron-loaded liver. However, the molecular mechanism leading to this observed phenomenon is currently poorly understood. In this study, all tumorous tissues from 24 HCC patients with chronic HBV infection were stained negative for iron when histologically assessed by Perls’ Prussian blue stain, whereas excess iron deposits were present in 17 of the 24 adjacent non-tumorous liver tissues. To elucidate the concerted regulation of iron homeostasis in these patients, we studied the gene expression profiling of 42 relevant iron-regulatory genes in the tumorous and adjacent non-tumorous liver tissues of these HCC patients along with 10 normal liver controls. Expression for most of the iron-regulatory genes, including hepcidin, transferrin receptor 2 (TfR2), transferrin (Tf), ceruloplasmin (Cp) and iron regulatory protein 1 (IRP1), were significantly down-regulated in the tumorous tissues of these patients compared to the adjacent non-tumorous liver tissues and normal liver controls. On the other hand, expression of hepcidin, TfR2, ferroportin 1 and DMT1 were significantly up-regulated in iron-loaded non-cirrhotic non-tumorous liver tissues as compared with normal liver controls. Hence, the reduction of hepcidin expression within the iron-depleted tumorous lesions likely reflects the physiological consequence of the obligate demand for iron in the rapidly growing neoplastic cells, whereas the up-regulation of hepcidin expression in the iron-loaded adjacent non-tumorous liver tissues is likely a physiological response.

HBME-1 and CK19 are highly discriminatory in the cytological diagnosis of papillary thyroid carcinoma

The cytologic diagnosis of papillary thyroid carcinoma is straightforward in most instances. However, there are some mimics including goitrous nodules and Hurthle cell neoplasms. Many studies have shown the combination of HBME-1 and CK19 expression to be useful in reaching a correct histologic diagnosis on tissue sections. We aim to assess the value of these markers in the setting of cell blocks prepared from needle aspiration specimens. We performed immunohistochemical staining of HBME-1 and CK19 on cell block material from 22 thyroid nodules that also had follow-up histology. Both CK19 and HBME-1 were strongly positive in all nine cases of papillary thyroid carcinoma, the latter showing distinct luminal accentuation. In the non-papillary carcinomas, none showed positivity for both HBME-1 and CK19. Two of six Hurthle cell neoplasms were positive for CK19, however all were negative for HBME-1. One of nine goitrous nodules was strongly positive for HBME-1 with luminal/membranous staining, but this were negative for CK19. The sensitivity, specificity and positive predictive value of HBME-1 in distinguishing between papillary thyroid carcinoma and goitrous nodules/Hurthle cell neoplasms were found to be 100%, 92.9% and 0.9, respectively; and that of HBME-1 and CK19 combination was 100%, 100% and 1. We thus conclude that the combination of positive HBME-1 (luminal/membranous) and CK 19 (cytoplasmic) staining on cell blocks of thyroid cytologic specimens is highly discriminatory in the diagnostic workup for papillary thyroid carcinoma.

Clinicopathological features of patients with concomitant intraductal papillary mucinous neoplasm of the pancreas and pancreatic endocrine neoplasm

BACKGROUND/AIMS

The occurrence of concomitant pancreatic endocrine neoplasm (PEN) and intraductal papillary neoplasm (IPMN) of the pancreas has rarely been reported. We describe our experience with 3 patients with this association and review the existing literature.

METHODS

From 1990 to 2005, 65 patients who underwent surgery for a PEN or IPMN were retrospectively reviewed. Forty-three patients had a PEN, 19 had an IPMN and 3 had both an IPMN and PEN. The 3 patients with concomitant IPMN and PEN are the focus of the current study and their clinicopathological features are reported together with 7 patients previously reported in the literature.

RESULTS

There were 10 patients with a median age of 62 years (range 40-73). The male:female ratio was equal. Seven of 10 patients were symptomatic and the most common symptoms were abdominal pain (n = 5), jaundice (n = 2) and loss of weight (n = 2). The median size of the endocrine neoplasms was 14 mm (range 2-30) and they occurred in the head (n = 3), body (n = 2) and tail (n = 5). Seven of the PENs were classified as benign, 2 were potentially malignant, and 1 was frankly malignant with lymph node involvement. None of the endocrine neoplasms were functioning. The IPMNs were found in the tail (n = 4), head (n = 3), head and body (n = 1), body (n = 1) and the entire pancreas (n = 1). Five of these neoplasms were benign, 2 were borderline and 3 were malignant (1 carcinoma in situ).

CONCLUSION

The occurrence of concomitant IPMN and PEN is more frequent than would be expected. However, it is difficult in the present analysis to determine if this association is more than just fortuitous.

Mapping of hereditary mixed polyposis syndrome (HMPS) to chromosome 10q23 by genomewide high-density single nucleotide polymorphism (SNP) scan and identification of BMPR1A loss of function

BACKGROUND

Hereditary mixed polyposis syndrome (HMPS) is characterised by colonic polyps of mixed histological types that are autosomal dominantly inherited and eventually lead to colorectal cancer (CRC). Study of the molecular basis of HMPS will enhance our knowledge of the genetic basis of the mixed polyposis-carcinoma sequence in both hereditary and sporadic CRC.

METHODS/RESULTS

We performed a genomewide linkage search on 15 members of a three-generation HMPS family using the GeneChip Human Mapping 10K Array and identified a 7 cM putative linkage interval on chromosome 10q23. Subsequently, 32 members from two HMPS families were typed with nine microsatellite markers spanning the region and the linkage was confirmed with a maximum multi-point logarithm of the odds (LOD) score of 4.6 (p<0.001). The 10q23.1-10q23.31 haplotypes segregate with the disease in both families. We screened for mutations in four candidate genes within the linkage region and identified an 11 bp deletion in the bone morphogenesis protein receptor 1A (BMPR1A) gene in one family.

CONCLUSIONS

Our results indicate that BMPR1A mutation accounts for HMPS. The data suggest that inactivating BMPR1A can initiate colorectal tumourigenesis via the mixed polyposis-carcinoma sequence.

Pathological features and their prognostic implications in colorectal endocrine cell tumours: a long-term follow-up study

AIMS

Long-term follow-up studies of colorectal endocrine cell tumours (CRECTs) are rare. Our aim was to correlate pathological features with metastatic potential and long-term survival of CRECTs.

METHODS

Pathological features of 35 CRECTs were reviewed. Features assessed were the tumour size, local and angio-invasion, growth pattern, cyto-nuclear morphology, mitotic count, mucin production and proliferative activity. CRECTs were also re-classified according to the World Health Organization (WHO) 2000 criteria. The follow-ups ranging from 60 to 132 months was obtained from Singapore National Cancer Registry data.

RESULTS

There were five metastatic and 30 non-metastatic tumours. Three of five metastatic tumours resulted in death within 1 year of diagnosis. Features exclusively seen in these three tumours were large size (25mm or more), mitoses > 6/10 high power fields with abnormal forms necrosis and large cell morphology. The features which correlated significantly with metastases were size, local and angioinvasion, primitive growth pattern, coarse chromatin and mitotic count (p < 0.0005), large cells and prominent nucleoli (p = 0.017), MIB1 proliferative index (p = 0.001) and abnormal mitoses and necrosis (p = 0.02). Thirty tumours were reclassified as well-differentiated endocrine cell tumours (WETs), three as well-differentiated endocrine cell carcinomas (WECs) and two were large cell neuroendocrine cell carcinomas (LECs) according to WHO criteria. One of the WECs and both LECs resulted in death.

CONCLUSIONS

All patients whose tumour was 25 mm or more, showing mitoses of more than 6 per 10 high power fields, with abnormal forms, necrosis and large cell morphology, died of the disease. Size, invasion, presence of discernible mitoses, coarse chromatin, 'primitive' growth pattern and MIB1 index of 4% or more were associated with metastases. LECs are rare but aggressive tumours resulting in early death. All WECs do not behave in the same fashion.

Correlation of histology with anorectal function following stapled hemorrhoidectomy

INTRODUCTION

The inadvertent removal of smooth muscle during the use of stapled hemorrhoidectomy had raised concerns about its effects on postoperative anorectal function. We correlated the amount of smooth muscle removed with anorectal function in the early postoperative period.

METHODS

Patients were assessed preoperatively with an Eypasch quality-of-life questionnaire and underwent anorectal manometry and physiology testing. This was followed by a similar examination at three months postoperatively. Patients were operated on by a single surgeon and the excised anorectal mucosa was sent for histologic examination. The amount of smooth muscle excised was expressed semiquantitatively as a percentage of the total tissue removed.

RESULTS

Sixty-eight patients (33 males) were recruited prospectively, with median age of 44 years. Six patients were lost to follow-up. Removal of anal transitional zone did not increase the incidence of incontinence. Both median preoperative and postoperative continence scores were good. Only one patient had incontinence to gas as a result of the operation. Median preoperative and postoperative quality-of-life scores were 114 and 131, respectively, out of a total of 144, the higher postoperative scores showing an improvement. Correlation of quality-of-life scores and mean resting anal pressures with percentage of smooth muscle removed did not show any statistical significance.

CONCLUSIONS

Some smooth muscle will invariably be excised in stapled hemorrhoidectomy but the amount of smooth muscle removed did not significantly affect the continence score, quality of life, or mean anal resting pressure after stapled hemorrhoidectomy. It remains a safe and preferred procedure for the treatment of hemorrhoids.

Clear Cell Papulosis of the Skin: A Case Report From Singapore

Clear cell papulosis of the skin is a rare condition; to our knowledge only 12 cases have been reported. Here, we report for the first time a case of clear cell papulosis with cytokeratin 7 expression and provide a comprehensive literature review. A 16-month-old girl presented with 3 hypopigmented lesions in the pubic region that were 3 to 9 mm in diameter; 1 lesion was papular, and the other 2 were macular. A skin biopsy revealed acanthosis with a proliferation of clear cells along the basal and suprabasal layers of the epidermis occurring in small clusters and singly. The cells had round to oval regular nuclei with abundant to moderate lightly eosinophilic to clear cytoplasm and intracytoplasmic mucin. Immunostaining produced positive results for carcinoembryonic antigen, AE1/3, epithelial membrane antigen, cell adhesion molecule 5.2, and cytokeratin 7 and negative results for gross cystic fluid disease protein, S100, and HMB-45. Clear cells of clear cell papulosis are mucin-positive and S100-negative glandular-secretory epithelial cells with histogenetic features of Toker cells of nipple and Paget cells. Immunohistochemical features support an eccrine secretory cell origin because the clear cells are consistently and strongly positive for carcinoembryonic antigen, positive for cell adhesion molecule 5.2, and negative or rarely positive for gross cystic fluid disease protein.

“Tap Sign” in Tuberculoid and Borderline Tuberculoid Leprosy

Deep pain upon percussion of lesions over bone in tuberculoid leprosy, in spite of superficial sensory impairment, has been described as the "Tap Sign" (TS). This study was conducted to identify possible causes for this phenomenon and to determine the sensitivity and specificity of this sign in leprosy patients with lesions overlying bone. In 37/53 patients with lesions over bone, the sensitivity of the TS was 66.7% and the specificity was 100%. The positive predictive value was 100%, and the negative predictive value was 75%. The Tap Sign appears to be a useful clinical sign in diagnosis of tuberculoid and borderline tuberculoid leprosy where a lesion overlies a bone (sensitivity 66.7%). This test could be very useful to increase the clinical diagnostic yield, in the global perspective, in places where leprosy is diagnosed and treated by healthcare workers and primary care physicians without other laboratory facilities. Possible mechanisms responsible for the deep pain are discussed.

Differentiating nonhigh-grade duct carcinoma in situ from benign breast lesions

This study was undertaken to determine the discriminating cytological features between nonhigh-grade duct carcinoma in situ (NHGDCIS) and benign breast lesions and to determine any histological characteristics which would influence the cytological categorization. Smears of 12 each of histologically confirmed NHGDCIS and benign breast lesions were reviewed with regard to cellularity, cell discohesion, nuclear atypia, crowding of cells, tubule formation, necrosis, and presence of bare atypical nuclei and regular bare bipolar nuclei, and statistically analyzed. Architectural pattern, presence of necrosis, and the size of the lesion assessed at histological examination were compared with the initial cytological categorization. NHGDCIS lesions showed more cell discohesion (P = 0.04), bare atypical nuclei (P = 0.05), necrosis (P = 0.03), and sparse bare bipolar nuclei (P = 0.02) than benign lesions. These differences were statistically significant. Cellularity (P = 0.8), nuclear atypia (P = 0.06), crowding of cells (P = 0.1), and tubule formation did not show a significant difference. Six (out of six lesions) with a solid architectural pattern and six (of seven) with necrosis could be cytologically categorized as suspicious or malignant. Size of the lesion did not influence this. We conclude that cell discohesion, bare atypical and bare bipolar nuclei, and necrosis are discriminating features between NHGDCIS and benign breast lesions and NHGDCIS lesions with a solid architectural pattern and necrosis are more likely to be satisfactorily categorized cytologically.

Cytohistologic features of invasive micropapillary carcinoma in a young female

Invasive micropapillary carcinoma (IMPC) is a recently reported variant of breast carcinoma in women. There has been only a single report describing the cytologic features of IMPC in the literature. We report on the cytohistologic features of IMPC with diffuse involvement of two quadrants of the breast and axillary lymph node metastases in a 32-yr-old female. The cytologic appearance of IMPC was characterized by high cellularity, marked cell discohesion, and epithelial cells forming aggregates, morules, and angular and papillary clusters without fibrovascular cores and showing high nuclear/cytoplasmic ratio, irregular nuclear contours, and finely stippled chromatin. Occasional psammoma bodies were noted. Histologic examination showed a pure IMPC composed of clusters, morules, and aggregates of malignant epithelial cells surrounded by distinctly clear spaces separated by thin fibrovascular septa. The tumor involved both inner quadrants and axillary lymph nodes. A primary tumor elsewhere, particularly in the ovaries, was excluded. The patient has been disease-free 38 mo after the initial diagnosis.

Itraconazole pulse therapy in chromoblastomycosis

Although daily itraconazole has been used effectively in chromoblastomycosis, there is no record of pulse therapy for chromoblastomycosis. A 68-year-old woman with a history of slowly enlarging scaly plaque involving the left shoulder and lateral chest, presented to the dermatology clinic at General Hospital, Kalutara, Sri Lanka. Clinically chromoblastomycosis was suspected. Direct KOH smears showed sclerotic bodies and histology showed granulomata with characteristic brown spores. Itraconazole (Sporanox) 200 mg. b.i.d. orally was given for a week followed by 3 drug free weeks. This cycle was repeated for 6 months (i.e. 7 pulses). Clinical improvement was visible by 2 months. Scrapings and biopsy repeated 5 months after the commencement of treatment were negative for chromoblastomycosis. The lesion had clinically healed by 5 months. Examination 8 months after cessation of treatment did not show any recurrence. Itraconazole pulse therapy is cheaper than daily treatment but effective in chromoblastomycosis. The optimal dosage and end point of treatment need to be ascertained after a larger study.

Tangles in smears of granulomatous lymphadenitis--a clue to the diagnosis

OBJECTIVE

To assess the significance and nature of tangles in fine needle aspiration biopsy (FNAB) smears of granulomatous lymphadenitis.

METHODS

The study group included 45 cases of clinically suspected granulomatous lymphadenitis particularly of tuberculous origin in which a cytologic diagnosis of granulomatous lymphadenitis (GL) was made on FNAB material. Smears of 21 lymph node aspirates without cytologic evidence of granulomatous disease (NGL) were included as a control group. One case with double pathology was excluded. All smears were fixed in 95% alcohol and stained with haematoxylin and eosin. Tangles were defined as a meshwork of haematoxyphilic string-like material occurring in a tangle in an otherwise well preserved smear. A score was given for the distribution (0-3) and density (1-3) of the tangles on the count of 10 high power fields for each aspirate. Statistical analysis was done by the Mann Whitney U test.

RESULTS

Tangles were present in 41 of 45 (91%) GL and 7 of 21 (33%) NGL. The differences were statistically significant (p = 0.0008 and 0.0001 for distribution and density respectively). Six of the seven (84%) NGL with tangles were either cytologically diagnostic or suspicious of malignancy with 5 (71%) showing features of non-Hodgkin's lymphoma. The tangles were positive for nuclear stains (Feulgen) and originated in the nuclei of both lymphocytes and epithelioid cells, probably due to easy fragility of altered nuclear material.

CONCLUSION

The presence of tangles in smears should raise the possibility of GL in the absence of a malignancy, specifically a lymphoma. This becomes an important diagnostic clue especially in situations where epithelioid histiocytes, the hall mark of GL, are sparse or absent in cytologic material.

Pitfalls in cytological diagnosis of autoimmune thyroiditis

The aims of this study are to document pitfalls in cytologic diagnosis of autoimmune thyroiditis (AT) and highlight possible ways to minimize them. One hundred consecutive thyroid aspirates with features diagnostic or suggestive of AT, performed and reported by the first author, were included in the study. Follow-up was traced and cytologic features responsible for indecisiveness were re-assessed in those reported as suggestive of AT. The features were then correlated with the results of serologic and thyroid function tests and clinical features, and an attempt was made to amend the final diagnosis using an integrated approach. Seventy eight were diagnostic and 22 were suggestive of AT. In the latter 22, features responsible for the indecisiveness were: cytologic atypia, in the form of nuclear enlargement, irregularity and grooves and altered chromatin texture, in 14 (64%); nucleoli with suspicion of a coexisting neoplasm in three (13.6%), two of which showed epithelial preponderance, crowding and discohesion; sparse inflammation in four (18%); a predominant lymphoid population without epithelial cells resembling a reactive lymph node in one (4.5%); co-existing toxic features in two (9%); and scanty smears in one (4.5%). Eighteen of the 22 suspected of AT had follow-up. Six had been assessed histologically; three with features suspicious of a neoplasm were diagnosed respectively as a papillary carcinoma (PC), Hurthle cell carcinoma (HCC) and a multinodular goitre (MNG) with degenerate changes. The other three were confirmed as AT; one with cytologic atypia, one with sparse inflammation and the third as cytologically resembling a reactive lymphnode. In ten of the remaining 12, the final diagnosis could be revised following an integrated approach with possible reduction of the indecisiveness. Potential pitfalls are: cytologic atypia occurring in AT; abundance or scarcity of background inflammation; low cell yield; and co-existing toxicity and malignancies. Epithelial preponderance over inflammation, nuclear crowding, severe atypia and cell discohesion should raise the possibility of a neoplasm in spite of other features of AT. Awareness of possible pitfalls and adopting an integrated approach, especially in difficult situations, will minimize pitfalls.

Cytomorphologic features of diffuse sclerosing variant of papillary carcinoma of the thyroid. A report of two cases in children

BACKGROUND

Diffuse sclerosing papillary carcinoma (DSPC), a variant of papillary carcinoma of thyroid, needs to be differentiated from classical papillary carcinoma and other variants. This variant is characterized by diffuse involvement of one or both thyroid lobes showing such histologic features as prominent sclerosis, an intense lymphocytic infiltrate, numerous psammoma bodies and squamous metaplasia together with the characteristic cytoarchitectural pattern of classical papillary carcinoma. Histologic and immuno-histochemical features have been described in previous publications. Although cytologic features of several variants of papillary carcinoma have been described previously, those of DSPC have not been widely published. The present report is on the cytomorphologic pattern of DSPC in two children, further highlighting the special features.

CASES

A boy, aged 11 years, presented with diffusely nodular, firm enlargement of the thyroid gland with many palpable lymph nodes, and a girl, aged 12 years, presented with diffusely nodular, firm enlargement of the left lobe with a prominent nodule on the lower pole. Fine needle aspiration biopsy (FNAB) smears stained with hematoxylin and eosin showed numerous psammoma bodies, many lymphocytes, metaplastic squamous cells and absent stringy colloid together with epithelial cells showing classical features of papillary carcinoma, such as nuclear grooves, intranuclear inclusions and papilloid structures. Histologic examination of the thyroidectomy specimens showed features of diffuse sclerosing variant of papillary carcinoma.

CONCLUSION

A diagnosis of DSPC should be considered when a combination of clinicocytologic features consisting of numerous psammoma bodies, lymphocytes, squamous metaplasia and absence of stringy colloid are noted with otherwise typical cytoarchitectural features of papillary carcinoma in FNAB smears obtained from diffusely nodular, firm thyroid enlargement.

Non-diagnostic smears in aspiration cytology of palpable breast lumps

The cytologic diagnoses of a wide variety of breast diseases have been described in the literature and cytologic appearances of some of these are not characteristic. Technical problems during aspiration and smear preparation influence the final diagnosis, therefore, even at best hands a non-diagnostic category is to be expected. The objectives of this study were to determine the frequency of non-diagnostic reports and to assess the source of indecisiveness. This study is based on a retrospective analysis of breast aspirates signed out by the first author over a period of 18 months. The smears with non-diagnostic reports were correlated with the available histologic follow-up to identify the problem area. Forty-eight (9.1%) out of the 527 samples were non-diagnostic and within the recorded range of 6.9% to 20%. Of those 48 in the non-diagnostic category, 30 (62.5%) had histological follow-up. There were 11 (36.7%) malignant lesions and 19 (63.3%) benign lesions. In 23 cases (77%) pure interpretative problems and in 3 cases (10%) pure technical problems were responsible for the non-diagnostic reports. In 4 cases (13%) both factors contributed to the non-diagnostic report. Thirteen of the 30 (43%) lesions were cytologically suspected to be malignant. Of these 13.9 (69%) were found to be malignant while only 4 were benign; thus non-diagnostic but suspicious lesions are more likely to be malignant. The commonest cytologic features responsible for problems at interpretation were high cellularity (37%), cell discohesion (30%), large nuclei and nucleoli (30%) and the small size of the cells (40%). Inadequate or low cell yield (86%), inadequate clinical history (14%) and poor staining (14%) contributed to technical problems. The cytologic diagnosis of breast lesions such as fibromatosis, complex sclerosing lesions, papillary lesions, angiosarcoma and low nuclear grade in situ and invasive carcinomas can be difficult and the cytologic criteria for these diagnoses need further evaluation.

Methanol as an alternative fixative for cytological smears

Ninety-five percent (95%) ethanol is the standard cytological fixative used in many laboratories. Commercially available ethanol is expensive and not freely available in some institutions. Methanol, a tissue dehydrant, is also known to be a cytological fixative. However its efficacy has not been assessed or documented in the literature. One hundred and eight consecutive fine needle aspiration biopsies (FNAB) of thyroid performed at the Department of Pathology, Faculty of Medicine, Colombo were included in a study to assess the efficacy of methanol as a cytological fixative. Aspirated material was smeared on at least 2 slides, one fixed in ethanol and the other in methanol, and stained with haematoxylin and eosin (H&E). The 2 smears were separately assessed for preservation of colloid and cells (nuclei and cytoplasm), as determined by the staining quality with the H&E stain. A score was given for each smear and the final scores for ethanol and methanol were statistically compared. The evaporation rates for ethanol and methanol were calculated. The total score for preservation of colloid was 294/300 (98%) for methanol and 291/300 (97%) for ethanol (p = 0.4). The total score for preservation of cells (nuclear and cytoplasmic) was 276/279 (98.9%) for methanol and 274/279 (98.2%) for ethanol (p = 0.7). The evaporation rates per 100 ml when the bottles used for fixation were kept closed and open per 24 hours were 1 and 37 for methanol and 0 and 17 for ethanol. Literature search did not show inhalational side effects of methanol in humans under standard laboratory conditions. We conclude that methanol is as effective as ethanol for fixation of smears and cheaper.

Cytology of granulomatous mastitis

OBJECTIVE

To examine the cytologic features of granulomatous mastitis.

STUDY DESIGN

Cytologic features of granulomatous mastitis (GM) are described as found on retrospective analysis of hematoxylin and eosin (H&E)-stained smears of nine breast lesions: eight fine needle aspiration biopsies and one imprint smear. All nine lesions were histologically confirmed.

RESULTS

The aspirates were moderate or abundant. The H&E smears showed a distinctly inflammatory background with multinucleated giant cells (both foreign body and Langhans type), debris, neutrophils, macrophages, epithelioid cells and reactive epithelial cells. Special histochemical stains did not reveal any specific organisms. No foamy cells or caseation was seen. The four patients who presented for follow-up were free of disease after a minimum of 6 and maximum of 38 months.

CONCLUSION

Although there are many entities mimicking GM, the cytologic pattern--consisting of multinucleated giant cells, debris, neutrophils, macrophages, epithelioid cells and reactive epithelial cells in the absence of foamy cells, caseation and demonstrable organisms--should prompt a diagnosis of GM.

First reports of subcutaneous sparganosis in Sri Lanka

OBJECTIVE

To report and create awareness of sparganosis, a parasitic zoonosis caused by a larval stage of Spirometra sp.

SETTING

Two patients with non-tender subcutaneous lumps. DIAGNOSIS CRITERIA: Morphology of solid cestode larva in excision biopsies.

CONCLUSIONS

Although these two instances were innocuous, infection is potentially dangerous as larvae are long lived and could invade vital organs. The most likely source of infection in Sri Lanka is ingestion of the infected first intermediate host, Cyclops, in water.

Chronic folliculitis in Sri Lanka

Chronic folliculitis (CF) is a chronic infection of hair follicles leading to atrophy and loss of the affected hairs. This study was done on 51 patients with CF presenting at the Dermatology Clinic at General Hospital Matara, Sri Lanka, to identify specific clinical features and aetiological factors, and to study histopathology. Pus cultures were done on 25 cases. Biopsies were done on 6 patients. CF was commoner in males (59%); 76% were under 34 years, and 39% had occupational exposure to possible irritants. Thirty five precent admitted of scrubbing legs with rough objects. Ichthyosis vulgaris was evident in 47%. All pus cultures revealed Staphylococcus aureus. Clinical features and histopathological features were similar to those described by Harman (1968). Rough scrubbing, ichthyosis and occupational exposure to irritants may be aetiologically relevant.

Fine needle sampling without aspiration

Four hundred and ten thyroid nodules, 127 breast lumps and 43 lymph nodes were sampled and analyzed to compare the classical aspiration (ASP) technique with the non aspiration needle jab (NASP) technique. The adequacy of cellularity, significant blood staining and the discomfort felt by the patient were assessed and statistically analyzed. The non aspiration technique was found to be superior to the classical aspiration technique for fine needle sampling of thyroid in all aspects. However, for breast lesions, while the discomfort felt and the staining with blood was less with the non aspiration technique, the overall cellular yield was unsatisfactory. The adequacy of cellular yield was, however, comparable for malignant breast lesions with either technique. For lymph node sampling, both techniques showed equivalent results with regard to the cellularity but, the NASP technique was superior in other aspects. Although the overall patient discomfort and blood staining was significantly less, the adequacy of the cellularity was influenced by the site and the nature of the lesion. Thus it can be concluded that the technique needs to be selected depending on the anatomic site, the clinical situation, the personal experience and the preference of the operator.

Necrotising lymphadenitis of Kikuchi and Fijimoto in Sri Lanka

We present the clinicopathological features of 10 patients with Kikuchi's lymphadenitis. It is important to distinguish this unusual form of necrotising lymphadenitis, both clinically and histologically, from lymphoma and infective lymphadenitis, including mycobacterial infection. The 10 lymph node biopsies studied were from young adults (9 women) with fever, cervical lymphadenopathy and elevated ESR. This is the first documentation of this condition in Sri Lanka. This benign self-limiting condition can be mistaken for lymphoma or infective lymphadenitis.

Aspiration cytology of breast lumps

The results of 287 aspirations performed on palpable breast lumps over a period of 20 months are presented. This is the first documentation of a Sri Lankan experience of this technique. The cytological assessment showed 52 malignant, 149 benign, 8 atypical, 6 suspicious and 72 inadequate aspirates. All lesions with a cytological diagnosis of malignancy were confirmed by histological assessment (False positives = 0). Histological follow up in 96 of the 149 cytologically benign lesions showed that 2 were malignant, giving a false negative rate of 2.1%. Three atypical lesions (37.5%) and four suspicious (66.2%) and 10 inadequate aspirates (13.7%) were also malignant.

Atypical presentations of pulmonary tuberculosis diagnosed by fibreoptic bronchoscopy

A total of 356 patients were subjected to fibreoptic bronchoscopy from September 1989 to June 1991 to exclude bronchial carcinoma. Bronchial biopsy, bronchial brush smears and bronchial wash were obtained. Bronchial wash was examined for acid fast bacilli (AFB) compatible with Mycobacterium tuberculosis. The total number diagnosed as pulmonary tuberculosis by fibreoptic bronchoscopy was 21(5.8%). The sputum smears were negative for AFB in all these patients. Previous studies have shown the importance of fibreoptic bronchoscopy in suspected cases of tuberculosis where the sputum smear is negative. This study is further evidence of the importance of routine examination of bronchial wash for AFB in all cases undergoing fibreoptic bronchoscopy to detect atypical cases of pulmonary tuberculosis.