PD-L1 Expression in Ampullary Adenocarcinoma

INTRODUCTION

Ampullary adenocarcinoma is a rare neoplasm often treated by the complex Whipple's procedure. Several histological factors predict poor prognosis including pancreatobiliary morphology, presence of lymphovascular, perineural invasion and local or distant metastasis. Systemic therapy with gemcitabine, 5-fluorouracil regimens are given with variable benefits. Immunotherapy checkpoint inhibitors have shown beneficial anti-tumor effects in several carcinomas, the most remarkable being in non-small cell lung cancer. Administration of these novel drugs is based on immunohistochemical expression (which may or may not be indicative of response to therapy) along with meticulous decision making by the multidisciplinary team. Immunohistochemistry (IHC) is an effective means of immune marker demonstration and has been used in various tumor types for predictive and prognostic purposes.

METHODS

PD-L1 IHC (clone E1L3N) was applied in 101 cases of ampullary adenocarcinoma. Tumor infiltrating lymphocytes were also evaluated. The immunoreactivity was assessed and categorized into following staining thresholds: <1%, <5%, <10% and ≥10% for tumor cells (membranous and/or cytoplasmic staining pattern), and 5% and 10% cut-offs for immune cells.

RESULTS

We found that at a 10% cut-off, 73.3% (74/101) patients were men (P  =  .006) older than 50 years of age (P < .001) presenting with a tumor measuring <3 cm (P  =  .001). It was significantly associated with intestinal differentiation (P  =  .004) and grade 1 tumors (P  =  .001). Twelve patients presented with recurrence as well (P  =  .03).

CONCLUSION

In the context of ampullary adenocarcinoma, this study highlights the positivity observed with the PD-L1 IHC clone E1L3N at different thresholds, with the particularly stronger associations being evident at a 10% cut-off.

From the archives of MD Anderson Cancer Center: Sporadic Burkitt lymphoma with a complex karyotype and SOX11 expression

Burkitt lymphoma (BL) is a mature B-cell neoplasm arising from germinal center B-cells. There are three epidemiological variants of which the sporadic variant is most prevalent in developed countries representing 1-2 % of all lymphomas in adults. Patients usually present with bulky abdominal masses and ~ 30 % have bone marrow involvement. BL is characterized by a germinal center B-cell immunophenotype and usually has a simple karyotype. Here we report an unusual case of sporadic BL in a 44-year-old man and we use this case to review sporadic BL in adults. The patient presented with a cecal mass and bone marrow involvement. Biopsy of the cecal mass and bone marrow evaluation showed infiltration by intermediate-size lymphoma cells positive for monotypic kappa, CD10, CD19, CD20, CD22, CD38 bright, CD43, CD45, Bcl6 and ROR1, and negative for CD11c, CD23, CD30, CD44, CD200 and Bcl2. As expected, the lymphoma cells were strongly positive for MYC and Ki-67 showed a proliferation rate of nearly 100 %, but the cells were also positive for SOX11 and cytoplasmic LEF1. Conventional chromosomal analysis revealed t(8;14) as part of a complex karyotype. Based on our literature review, and is shown in this case, sporadic BL in adults shows some differences with the classic description of BL in children. We also discuss the differential diagnosis of BL.

Non-Small Cell Lung Cancer: Targetable Variants in Concurrent Tissue and Liquid Biopsy Testing in a North Indian Cohort

OBJECTIVES

Testing for EGFR, ALK, ROS1 and MET alterations in paired tissue and plasma samples of treatment-naïve patients of NSCLC and correlating their status with overall survival.

MATERIALS AND METHODS

One hundred treatment-naïve patients were recruited after obtaining informed consent. Ten ml of blood was collected within a period of two weeks from histological diagnosis, prior to the start of any treatment. DNA & RNA extraction was done from formalin-fixed paraffin embedded (FFPE) tissue and total cell-free nucleic acid extraction was done from plasma samples. EGFR mutation, ALK, ROS1 and MET rearrangements were tested by ARMS (Amplification Refractory Mutation System) PCR. All statistical analyses were conducted in R version 4.1.1.

RESULTS

A total of 61 cases showed molecular alterations in tissue samples which included EGFR mutations (47), ALK rearrangements (12), ROS1 fusion (2). MET alteration was not detected. Forty-three cases showed EGFR mutations in plasma, 26 of which were concurrently positive in tissue. Concordance observed was 62%. ALK-EML4 rearrangement, ROS1 fusion and MET were not detected in plasma samples. Sensitivity and specificity for detection of EGFR mutation in plasma were 55.3% and 67.9% respectively. Univariate Cox regression analysis showed a positive association between EGFR mutation in tissue and overall survival (HR = 0.4; 95% CI: 0.2-0.7; p = 0.003) and improved overall survival in those who received targeted therapy (HR = 0.29; 95% CI: 0.1-0.8; p = 0.02).

CONCLUSION

Concurrent testing in tissue and liquid biopsy in NSCLC increased the detection of EGFR mutations (47% to 64%). This has substantial implications in deciding treatment and administration targeted therapy and the consequent overall survival.

Histopathological Spectrum in Pancreaticoduodenectomy Specimens: Fifteen Year Study from a Tertiary Care Centre in North India

Introduction/Objective

The periampullary region is histologically complex owing to the confluence of three different kinds of epithelia (duodenal, pancreatic, biliary) harbouring four types of cancers. Although anatomical proximity warrants a common surgical approach, overall survival depends largely on the type of surgical indication. Malignant epithelial tumors are the predominant indications, accompanied by a myriad of benign tumors and tumor-like lesions. We reviewed our archival pancreaticoduodenectomies to analyze the spectrum of these lesions.

Methods

All pancreaticoduodenectomy specimens received in Department of Pathology, from 2005–2019 (15 years) were analyzed for histological spectrum.

Results

A total of 786 pancreaticoduodenectomies were received with an overall M:F= 2.3:1 and age range 17–91 years. Of these, 94.4% were neoplastic (742 cases) and 5.6% were non-neoplastic. Benign neoplastic lesions (19 cases, 2.4%) included adenomyoma (7 cases, 0.9%), solid-cystic pseudopapillary tumor of pancreas (5 cases, 0.6%), intraductal papillary mucinous neoplasm (2 cases, 0.3%) and one case each of serous cystadenoma, mucinous cystic neoplasm, dermoid cyst, gangliocytic paraganglioma and Peutz-Jeghers polyp. Ampullary adenocarcinoma was the predominant malignant epithelial lesion (609 cases, 77.5%) followed by distal CBD cancer (43 cases, 5.5%), pancreatic head cancer (20 cases, 2.5%), neuroendocrine tumors (22 cases, 2.8%), carcinoma gallbladder (5 cases, 0.6%) and one case of ampullary adenosquamous carcinoma (0.1%). Non-epithelial tumors included 9 cases of GIST (1.1%), 3 of carcinosarcoma and one case each of leiomyosarcoma and lymphoma. Non-neoplastic lesions (3.2%) included 22 cases of chronic pancreatitis and one case each of xanthogranulomatous pancreatitis, lymphoplasmacytic slcerosing pancreatitis and xanthogranulomatous cholecystitis. Ectopic pancreas was rare (2 cases, 0.3%) and 16 cases (2%) were negative for any specific pathology.

Conclusion

This is the largest data on histological spectrum of pancreaticoduodenectomies from India. The malignant lesions form the major bulk (94%), however benign lesions also account for a substantial percentage of surgical indications. Among malignant lesions, ampullary cancers outreach far above pancreatic cancers in the Indian subcontinent.

Prevalence of erectile dysfunction and its correlates among men attending primary care clinics in three countries: Pakistan, Egypt, and Nigeria

The prevalence and correlates of erectile dysfunction (ED) in developing countries are largely unknown. Our objectives were to determine the prevalence and associated factors of ED in three countries (Pakistan, Egypt, Nigeria) that represent very different cultures. Men 35-70y of age seeking primary medical care answered a structured questionnaire adapted to reflect local cultures. Degree of ED was categorized as 'none,' 'mild,' 'moderate,' or 'complete.' The age-adjusted prevalence rates of ED among men attending primary care clinics was 57.4% in Nigeria, 63.6% in Egypt, and 80.8% in Pakistan. Older age, diabetes, peptic ulcers, prostate disease, depression-related symptoms, and caffeine consumption were independently associated with increased prevalence of ED, whereas being moderately active to very active at work (hard physical labor) and during leisure time (strenuous exercise) was associated with half the prevalence of moderate-to-complete ED. Our multicultural study demonstrates that in every country studied, high proportions of men older than age 35 have some degree of ED (57-81%). Both severity and prevalence increase consistently with age. Factors associated with ED are similar, but their distribution differs across countries.

Test of a criterion for selecting intracranial doses of angiotensin receptor blockers

Investigators using intracerebroventricular (ICV) injections of competitive antagonists of angiotensin II (Ang II) to study thirst usually select doses sufficient to block drinking to IV Ang II. We questioned whether this test truly indicates the dose needed under physiological conditions when Ang II-induced hypertension, which inhibits thirst, is not present. Rats were prepared with chronic venous and ICV cannulas, plus femoral arterial cannulas in those used to measure arterial pressure. Captopril (100 mg/kg SC) was given before all experiments to block endogenous Ang II production. The test dose of Ang II, 50 ng/kg/min IV for 1 hr, increased water intake and arterial pressure. We selected an ICV dose of saralasin (Sar1Ala8Ang II), 4 micrograms bolus and 4 micrograms/hr for 75 min, that did not stimulate drinking itself and completely blocked drinking to IV Ang II. This dose of saralasin only partially (45%) reduced drinking to the same dose of Ang II IV when arterial pressure was lowered by giving the vasodilator diazoxide (15 mg/kg IV). Diazoxide itself did not stimulate drinking. These results support our concern that the criterion normally used to select ICV doses of Ang II antagonists probably underestimates the amount needed to inhibit angiotensinergic drinking in hypovolemic or hypotensive animals.