Intraoperative assessment of axillary sentinel lymph nodes by telepathology

PURPOSE

Although axillary dissection is no longer indicated for many breast cancer patients with 1-2 positive axillary sentinel lymph nodes (ASLN), intraoperative ASLN assessment is still performed in many institutions for patients undergoing mastectomy or neoadjuvant therapy. With recent advancements in digital pathology, pathologists increasingly evaluate ASLN via remote telepathology. We aimed to compare the performance characteristics of remote telepathology and conventional on-site intraoperative ASLN assessment.

METHODS

Data from ASLN evaluation for breast cancer patients performed at two sites between April 2021 and October 2022 was collated. Remote telepathology consultation was conducted via the Aperio eSlideManager system.

RESULTS

A total of 385 patients were identified during the study period (83 telepathology, 302 on-site evaluations). Although not statistically significant (P = 0.20), the overall discrepancy rate between intraoperative and final diagnoses was slightly higher at 9.6% (8/83) for telepathology compared with 5.3% (16/302) for on-site assessment. Further comparison of performance characteristics of ASLN assessment between telepathology and conventional on-site evaluation revealed no statistically significant differences between deferral rates, discrepancy rates, interpretive or sampling errors, major or minor disagreements, false negative or false positive results as well as clinical impact and turn-around time (P ≥ 0.12).

CONCLUSION

ASLN assessment via telepathology is not significantly different from conventional on-site evaluation, although it shows a slightly higher overall discrepancy rate between intraoperative and final diagnoses (9.6% vs. 5.3%). Further studies are warranted to ensure accuracy of ASLN assessment via telepathology.

Bilateral breast Rosai-Dorfman disease screen detected by mammography

Rosai-Dorfman disease (RDD) is a proliferative disorder of histiocytes typically found in nodal sites and commonly observed in females. Patients often present with systemic symptoms such as fever, lymphadenopathy, and weight loss. However, extra-nodal disease has been identified in locations including the skin and subcutaneous tissue. We present a case of a 59-year-old female presenting with abnormal bilateral findings on screening mammography, who was found to have a rare presentation of Rosai-Dorfman disease.

Efficacy of endoscopic ultrasound-guided fine-needle aspiration and core needle biopsy in the diagnosis of upper gastrointestinal submucosal lesions

INTRODUCTION

Endoscopic ultrasonographically guided fine-needle aspiration (EUS-FNA) has been increasingly utilized to evaluate submucosal lesions of the upper gastrointestinal (UGI) tract. Our study aims to determine the efficacy of UGI EUS-FNA/core needle biopsy (CNB), including the frequency and cytomorphologic features of encountered submucosal lesions, and to investigate contributing factors including the role of rapid on-site evaluation (ROSE).

METHODS

We analyzed all UGI submucosal lesions diagnosed at our institution by EUS-FNA/CNB from September 2008 through August 2015.

RESULTS

During this 8-year study period, 94 patients underwent 110 UGI EUS-FNA/CNB, including 89 (81%) gastric, 11 (10%) duodenal, and 10 (9%) esophageal lesions. Twenty-seven (25%) were gastrointestinal stromal tumors (GISTs), followed by 13 (12%) leiomyomas, 5 (5%) schwannomas, 4 (4%) gastric adenocarcinomas, 3 (3%) neuroendocrine tumors (NETs), and 3 (3%) pancreatic heterotopias. All GISTs, leiomyomas, and NETs were ultimately diagnosed by EUS biopsies, as well as 75% of adenocarcinomas, 60% of schwannomas, and 33% of pancreatic heterotopias. The specificity of EUS-FNA/CNB for these 6 most commonly encountered lesions was 100%, with sensitivity of 82%. Sensitivity was 100% for esophageal and duodenal biopsies, and 80% and 75% for gastric and gastroesophageal procedures, respectively. Factors that contributed to poor yield included the lack of ROSE, small lesional size, lesion location and histology, and needle type. Neither number of needle passes nor operator experience appeared to influence specimen adequacy.

CONCLUSION

EUS-FNA/CNB is an effective modality for diagnosing UGI submucosal lesions. Awareness of potential errors due to sampling of the bowel wall, lesional cystic degeneration, as well as pancreatic heterotopia and Brunner gland hamartoma is essential in order to avoid false diagnoses.

Double staining: diagnostic utility in non-small cell lung carcinoma in the era of tissue conservation

INTRODUCTION

In an era of precision medicine distinguishing pulmonary squamous cell carcinoma (SQCC) from adenocarcinoma (ADC) is vital for treatment. Immunohistochemical (IHC) staining for p40, p63 and Cytokeratin 5 (CK5) are useful for SQCC, while TTF-1 and Napsin-A can be used for confirming ADC. Fine needle aspiration (FNA) cell blocks (CB) have limited tissue, hence, double IHC staining is helpful for tissue conservation for molecular analysis.

MATERIALS AND METHODS

Thirty six confirmed lung SQCC and 45 ADC CB were selected for IHC. Double staining was performed with p40/CK5 and p63/CK5 on all SQCC, and with TTF-1/Napsin-A on all ADC. Results were positive if at least 5% of malignant cells were immunoreactive for the antigen.

RESULTS

P40/CK5 had (92%) sensitivity, (100%) specificity, (100%) positive predictive value (PPV), (91%) negative predictive value (NPV) and an overall diagnostic accuracy of (96%). By contrast, P63/CK5 double stains showed (92%) sensitivity, (80%) specificity, (85%) PPV, (89%) NPV and (86%) overall diagnostic accuracy, respectively. TTF-1/Napsin A staining for ADC showed a sensitivity of 80%, specificity of 96%, PPV of 97%, NPV of 71% and accuracy of 85%.

CONCLUSION

P40/CK5 double stain has higher specificity, PPV, NPV, and overall accuracy than P63/CK5 double stain in the diagnosis of lung SQCC. TTF-1/Napsin-A double staining is a valuable marker with high specificity, PPV, and diagnostic accuracy in diagnosing lung ADC. The usage of P40/CK5 and TTF-1/Napsin-A as a panel can be recommended for characterizing non-small cell carcinoma (NSCC) of the lung and for conserving tissue for molecular testing.