Serum biomarkers correlated with liver stiffness assessed in a multicenter study of pediatric cholestatic liver disease

BACKGROUND AND AIMS

Detailed investigation of the biological pathways leading to hepatic fibrosis and identification of liver fibrosis biomarkers may facilitate early interventions for pediatric cholestasis.

APPROACH AND RESULTS

A targeted enzyme-linked immunosorbent assay-based panel of nine biomarkers (lysyl oxidase, tissue inhibitor matrix metalloproteinase (MMP) 1, connective tissue growth factor [CTGF], IL-8, endoglin, periostin, Mac-2-binding protein, MMP-3, and MMP-7) was examined in children with biliary atresia (BA; n = 187), alpha-1 antitrypsin deficiency (A1AT; n = 78), and Alagille syndrome (ALGS; n = 65) and correlated with liver stiffness (LSM) and biochemical measures of liver disease. Median age and LSM were 9 years and 9.5 kPa. After adjusting for covariates, there were positive correlations among LSM and endoglin ( p = 0.04) and IL-8 ( p < 0.001) and MMP-7 ( p < 0.001) in participants with BA. The best prediction model for LSM in BA using clinical and lab measurements had an R2 = 0.437; adding IL-8 and MMP-7 improved R2 to 0.523 and 0.526 (both p < 0.0001). In participants with A1AT, CTGF and LSM were negatively correlated ( p = 0.004); adding CTGF to an LSM prediction model improved R2 from 0.524 to 0.577 ( p = 0.0033). Biomarkers did not correlate with LSM in ALGS. A significant number of biomarker/lab correlations were found in participants with BA but not those with A1AT or ALGS.

CONCLUSIONS

Endoglin, IL-8, and MMP-7 significantly correlate with increased LSM in children with BA, whereas CTGF inversely correlates with LSM in participants with A1AT; these biomarkers appear to enhance prediction of LSM beyond clinical tests. Future disease-specific investigations of change in these biomarkers over time and as predictors of clinical outcomes will be important.

Risk of variceal hemorrhage and pretransplant mortality in children with biliary atresia

BACKGROUND AND AIMS

The natural history of gastroesophageal variceal hemorrhage (VH) in biliary atresia (BA) is not well characterized. We analyzed risk factors, incidence, and outcomes of VH in a longitudinal multicenter study.

APPROACH AND RESULTS

Participants enrolled in either an incident (Prospective Database of Infants with Cholestasis [PROBE]) or prevalent (Biliary Atresia Study of Infants and Children [BASIC]) cohort of BA were included. Variceal hemorrhage (VH) was defined based on gastrointestinal bleeding in the presence of varices accompanied by endoscopic or nontransplant surgical intervention. Cumulative incidence of VH and transplant-free survival was compared based on features of portal hypertension (e.g., splenomegaly, thrombocytopenia) and clinical parameters at baseline in each cohort (PROBE: 1.5 to 4.5 months after hepatoportoenterostomy [HPE]; BASIC: at enrollment > 3 years of age). Analyses were conducted on 869 children with BA enrolled between June 2004 and December 2020 (521 in PROBE [262 (51%) with a functioning HPE] and 348 in BASIC). The overall incidence of first observed VH at 5 years was 9.4% (95% CI: 7.0-12.4) in PROBE and 8.0% (5.2-11.5) in BASIC. Features of portal hypertension, platelet count, total bilirubin, aspartate aminotransferase (AST), albumin, and AST-to-platelet ratio index at baseline were associated with an increased risk of subsequent VH in both cohorts. Transplant-free survival at 5 years was 45.1% (40.5-49.6) in PROBE and 79.2% (74.1-83.4) in BASIC. Two (2.5%) of 80 participants who had VH died, whereas 10 (12.5%) underwent transplant within 6 weeks of VH.

CONCLUSIONS

The low risk of VH and associated mortality in children with BA needs to be considered in decisions related to screening for varices and primary prophylaxis of VH.

Adherence to Biopsy and Follow-Up Guidelines in a Population-Based Cohort of Children With Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated condition that is becoming more widely recognized in children. Recent EoE practice guidelines provide clear recommendations on adequate biopsy sampling at diagnostic endoscopy and necessity of close follow-up endoscopy with biopsy to ensure mucosal healing with therapy.¹ Despite these recommendations, adherence to biopsy guidelines, time to first follow-up endoscopy, and overall surveillance endoscopy rates have not been robustly studied. Using a population-based cohort of children diagnosed with EoE in Utah, we assessed adherence to guidelines across multiple provider types, including academic pediatric gastroenterologists (PGIs), private practice PGIs, and adult-trained providers performing endoscopy in children.

Incidence and Prevalence of Pediatric Eosinophilic Esophagitis in Utah Based on a 5-Year Population-Based Study

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) is often detected in children and is considered to be a rare disease, with prevalence values reported to be below 60 cases per 100,000 persons. To determine whether the incidence of EoE in children in Utah exceeds estimates from regional reports, we calculated incidence and prevalence values over a 5-year period.

METHODS

Using consensus guidelines for the diagnosis of EoE, we reviewed pathology records from the Intermountain Healthcare pathology database, from July 1, 2011 through June 31, 2016. We collected data on 10,619 pediatric patients with available esophageal biopsy results, and identified cases of esophageal eosinophilia (>14 eosinophils in a high-power microscopy field in an endoscopic biopsy). An EoE case required the presence of esophageal eosinophilia, symptoms of esophageal dysfunction, and the absence of co-morbid conditions that may cause esophageal eosinophilia. Annual pediatric EoE incidence and prevalence values were calculated per 100,000 children, based on averaged pediatric population estimates from census figures of Utah in 2010 and 2016.

RESULTS

We identified 1281 unique pediatric patients who met criteria for esophageal eosinophilia. Of those, 1060 patients met criteria for newly diagnosed EoE. Over the 5-year period studied, the average annual pediatric EoE incidence in Utah was 24 cases per 100,000 children. The prevalence in year 5 of the study was 118 cases per 100,000 children.

CONCLUSION

In a population-based study of children in Utah, we found the incidence and prevalence of pediatric EoE to be higher than previously reported. This could be due to the prominence of EoE risk factors in this region, as well as Utah's searchable medical record system that allows for reliable case ascertainment. Further studies of this type could increase disease awareness, prompting early referral to pediatric gastroenterologists and trials to strengthen evidence-based, algorithmic approaches to EoE diagnosis and treatment in children.

H syndrome: 5 new cases from the United States with novel features and responses to therapy

BACKGROUND

H Syndrome is an autosomal recessive disorder characterized by cutaneous hyperpigmentation, hypertrichosis, and induration with numerous systemic manifestations. The syndrome is caused by mutations in SLC29A3, a gene located on chromosome 10q23, which encodes the human equilibrative transporter 3 (hENT3). Less than 100 patients with H syndrome have been described in the literature, with the majority being of Arab descent, and only a few from North America.

CASE PRESENTATION

Here we report five pediatric patients from three medical centers in the United States who were identified to have H syndrome by whole exome sequencing. These five patients, all of whom presented to pediatric rheumatologists prior to diagnosis, include two of Northern European descent, bringing the total number of Caucasian patients described to three. The patients share many of the characteristics previously reported with H syndrome, including hyperpigmentation, hypertrichosis, short stature, insulin-dependent diabetes, arthritis and systemic inflammation, as well as some novel features, including selective IgG subclass deficiency and autoimmune hepatitis. They share genetic mutations previously described in patients of the same ethnic background, as well as a novel mutation. In two patients, treatment with prednisone improved inflammation, however both patients flared once prednisone was tapered. In one of these patients, treatment with tocilizumab alone resulted in marked improvement in systemic inflammation and growth. The other had partial response to prednisone, azathioprine, and TNF inhibition; thus, his anti-TNF biologic was recently switched to tocilizumab due to persistent polyarthritis. Another patient improved on Methotrexate, with further improvement after the addition of tocilizumab.

CONCLUSION

H syndrome is a rare autoinflammatory syndrome with pleiotropic manifestations that affect multiple organ systems and is often mistaken for other conditions. Rheumatologists should be aware of this syndrome and its association with arthritis. It should be considered in patients with short stature and systemic inflammation, particularly with cutaneous findings. Some patients respond to treatment with biologics alone or in combination with other immune suppressants; in particular, treatment of systemic inflammation with IL-6 blockade appears to be promising. Overall, better identification and understanding of the pathophysiology may help devise earlier diagnosis and better treatment strategies.

Biochemical abnormalities in Pearson syndrome

Pearson marrow-pancreas syndrome is a multisystem mitochondrial disorder characterized by bone marrow failure and pancreatic insufficiency. Children who survive the severe bone marrow dysfunction in childhood develop Kearns-Sayre syndrome later in life. Here we report on four new cases with this condition and define their biochemical abnormalities. Three out of four patients presented with failure to thrive, with most of them having normal development and head size. All patients had evidence of bone marrow involvement that spontaneously improved in three out of four patients. Unique findings in our patients were acute pancreatitis (one out of four), renal Fanconi syndrome (present in all patients, but symptomatic only in one), and an unusual organic aciduria with 3-hydroxyisobutyric aciduria in one patient. Biochemical analysis indicated low levels of plasma citrulline and arginine, despite low-normal ammonia levels. Regression analysis indicated a significant correlation between each intermediate of the urea cycle and the next, except between ornithine and citrulline. This suggested that the reaction catalyzed by ornithine transcarbamylase (that converts ornithine to citrulline) might not be very efficient in patients with Pearson syndrome. In view of low-normal ammonia levels, we hypothesize that ammonia and carbamylphosphate could be diverted from the urea cycle to the synthesis of nucleotides in patients with Pearson syndrome and possibly other mitochondrial disorders.

Eosinophilic esophagitis in adults is associated with IgG4 and not mediated by IgE

BACKGROUND & AIMS

Eosinophilic esophagitis is usually triggered by foods, by unclear mechanisms. We evaluated the roles of IgE and IgG4 in the development of eosinophilic esophagitis.

METHODS

We performed a prospective, randomized, double-blind, placebo-controlled trial of adults with eosinophilic esophagitis given an antibody against IgE (omalizumab, n = 16) or placebo (n = 14) every 2-4 weeks for 16 weeks, based on weight and serum level of IgE. Endoscopy was performed, esophageal biopsy specimens were collected, and symptoms were assessed at baseline and at 16 weeks. Maximum numbers of eosinophils/high-power field were determined. Homogenates of esophageal biopsy specimens from 11 subjects with eosinophilic esophagitis and 8 without (controls) were assessed for IgM, IgA, and IgG subclasses. In a retrospective analysis, we performed immunofluorescence analysis of IgG4 in fixed esophageal tissues from 2 patients with eosinophilic esophagitis who underwent esophagectomy and 47 consecutive autopsies (controls). We also performed immunofluorescence analysis of IgG4 in esophageal mucosal biopsy specimens from 24 subjects with eosinophilic esophagitis and 9 without (controls). Finally, sera were collected from 15 subjects with eosinophilic esophagitis and from 41 without (controls), and assayed for total and food-reactive IgG4.

RESULTS

Omalizumab did not alter symptoms of eosinophilic esophagitis or eosinophil counts in biopsy samples compared with placebo. Homogenates of esophageal tissues from patients with eosinophilic esophagitis had a 45-fold increase in IgG4 compared with controls (P < 3 × 10(-5)), but no significant increases in other IgG subclasses, IgM, or IgA. Sparse stromal deposits resembling immune complexes were found in 2 of 5 eosinophilic esophagitis biopsy specimens based on ultrastructural analysis. Esophagectomy samples from 2 patients with eosinophilic esophagitis contained 180 and 300 IgG4 plasma cells/maximal high-power field, mainly in the deep lamina propria; these levels were greater than in tissues from controls. Fibrosis essentially was exclusive to the lamina propria. Granular extracellular IgG4 was detected in biopsy specimens from 21 of 24 patients with eosinophilic esophagitis, but in none of the specimens from 9 controls (P = 6 × 10(-6)). The total serum level of IgG4 increased only slightly in patients with eosinophilic esophagitis, compared with controls. Subjects with eosinophilic esophagitis had increased serum levels of IgG4 that reacted with milk, wheat, egg, and nuts-the 4 foods that most commonly trigger this condition (P ≤ 3 × 10(-4) for each food).

CONCLUSIONS

In a prospective trial, omalizumab did not reduce symptoms of eosinophilic esophagitis or tissue eosinophil counts compared with placebo. This finding, along with observed granular deposits of IgG4, abundant IgG4-containing plasma cells, and serum levels of IgG4 reactive to specific foods, indicate that, in adults, eosinophilic esophagitis is IgG4-associated, and not an IgE-induced allergy. ClinicalTrials.gov number: NCT 00123630.

Endoscopy in the diagnosis of intestinal graft-versus-host disease: is lower endoscopy with biopsy as effective in diagnosis as upper endoscopy combined with lower endoscopy?

BACKGROUND

Graft-versus-host disease (GvHD) causes morbidity and mortality in recipients of hematopoietic stem cell transplantation (SCT). This study assessed the distribution of GvHD in gastrointestinal (GI) biopsies from the upper and lower GI tract in pediatric patients who had undergone SCT and evaluated if there was correlation between biopsy findings and possible extra-intestinal manifestations of GvHD.

PROCEDURE

We performed a retrospective chart review for all patients diagnosed with GvHD, who underwent both upper and lower endoscopy. We also reviewed pathology and clinical reports to determine which biopsy sites were diagnostic of GvHD and to evaluate for the possible presence of extra-intestinal manifestations GvHD at the time of biopsy.

RESULTS

Twenty patients were identified who had undergone both upper and lower endoscopy for evaluation of GvHD. Patients with GvHD diagnosed on upper endoscopy also had GvHD identified in the sigmoid colon region 100% of the time (positive predictive value [PPV] = 1). In patients that were found to have underlying liver disease, GvHD was diagnosed in the sigmoid colon region 90% of the time (PPV = 0.9).

CONCLUSION

Use of sigmoid biopsy for GvHD diagnosis is effective, safe, and less expensive compared to other endoscopic interventions.

Granulomatous appendicitis in a child

Granulomatous appendicitis (GA) is a rare inflammatory condition affecting the appendix. We report a pediatric patient with GA in which symptoms resolved after appendectomy. Although the colon was grossly normal by endoscopy, microscopic examination revealed colitis without granuloma formation. GA may represent a variant of inflammatory bowel disease (IBD).

The Stillbirth Collaborative Research Network (SCRN) placental and umbilical cord examination protocol

The Stillbirth Collaborative Research Network (SCRN) was organized to study the scope and causes of stillbirth (SB) in the United States. The objective of this report is to describe the approach used for the placental examination performed as part of the study. The SCRN consists of a multidisciplinary team of investigators from five clinical sites, the National Institute of Child Health and Human Development, and the Data Coordination and Analysis Center. The study is a population-based cohort and nested case-control study, with prospective enrollment of women with SB and live births (LB) at the time of delivery. Detailed and standardized postmortem examination was performed on SB and placental examination in both groups. A total of 663 women with SB and 1932 women with LB were enrolled into the case-control study. In the SB group, there were 707 fetuses. Of these cases, 654 (98.6%) had placental examination. Of these LB controls, 1804 (93.4%) had placental examination. This is the largest prospective study to include population-based SB and LB, using standardized postmortem and placental examination, medical record review, maternal interview, collection of samples, and a multidisciplinary team of investigators collaborating in the analyses. Thus it has the potential to provide high-level evidence regarding the contribution of placental abnormalities to stillbirth.

Yolk sac tumor of the thyroid gland: a case report

Extragonadal yolk sac tumors are uncommon and usually seen in sacrococcygeal, mediastinal, intracranial, and retroperitoneal sites. Yolk sac tumors of the head and neck region are rare, and the few reported cases have arisen in neonates or infants in conjunction with a teratoma or other germ cell tumor subtypes. We report a unique case of a pure yolk sac tumor presenting as a primary lesion in the right thyroid lobe of a 10-year-old girl. The diagnosis was suspected after fine-needle aspiration, and extensive sampling of the thyroidectomy specimen revealed no teratoma or other germ cell tumor. Serum α-fetoprotein levels were markedly elevated 6 days after excision, and imaging disclosed numerous bilateral pulmonary nodules suggestive of metastatic disease but did not reveal a mediastinal mass. The tumor has shown a favorable response to bleomycin, etoposide, and cisplatin chemotherapy. To the best of our knowledge, this is the 1st description of a primary pure yolk sac tumor of the thyroid.

Plasmapheresis treatment of antibody-mediated rejection in an A2 donor to O pediatric liver transplant recipient

It is safe to transplant kidneys from blood group A2 donors into O recipients if the latter have low titers of anti-A antibodies. However, in liver transplantation, O and B recipients of A2 donor livers are not routinely screened for anti-blood group antibodies because of the immuno-absorptive capacity of the liver and the low incidence of antibody-mediated rejection. Herein, we report a rare case of combined cell and antibody-mediated rejection in a pediatric blood group O recipient of an A2 donor liver, and rescue of the allograft using PP and IVIG.

Unilateral sclerocornea and tracheal stenosis: unusual findings in a patient with Goldenhar anomaly

The Goldenhar anomaly (GA) is a heterogeneous field defect of uncertain cause and wide variability of expression, characterized by facial phenotypes, usually asymmetric and unilateral, accompanied by various combinations and gradations of cardiac, skeletal, renal, and central nervous system defects. We report the pathologic findings in a 5-month-old boy with GA, tracheal stenosis, and left unilateral sclerocornea. To the best of our knowledge this is the first description of sclerocornea in a patient with GA.

Critical values in pediatric surgical pathology: definition, implementation, and reporting in a children's hospital

Timely communication of significant or unexpected findings in surgical pathology can significantly improve patient care. Although surgical pathology critical values have been published, no systematic assessment in pediatric surgical pathology has been published. We surveyed pediatric pathologists and pediatric subspecialists to develop pediatric surgical pathology critical values for verbal reporting before the final pathology report. A policy and process for reporting and documentation was implemented, with retrospective and prospective quality review. Critical values cases constituted 9.4% of surgical pathology accessions. Retrospective analysis revealed that 80% (73/91) had been reported and documented before policy implementation. Following implementation, 97.3% (402/413) were verbally reported and documented. A multidisciplinary group provided valuable information about critical values that might not have been obvious to pediatric pathologists but are important for patient care. Although the term critical values has become embedded in the surgical pathology literature, we would propose an alternative term for significant or unexpected findings that require timely communication and documentation.

Fibroepithelial polyp of the prostatic urethra in an adolescent

Benign fibroepithelial polyp of the prostatic urethra is a rare congenital lesion most commonly diagnosed in the pediatric population because of diverse urinary symptoms. We report a case of a 16-year-old adolescent boy who presented with urinary retention. Imaging and endoscopic studies confirmed the presence of a polypoid lesion at the bladder base/posterior prostatic urethra. Following transurethral resection of this polypoid mass, the diagnosis of a congenital fibroepithelial polyp of the prostatic urethra was rendered by pathologic evaluation. Although this is considered a benign lesion with no previous reports of recurrence or malignant behavior, it produces dramatic urinary symptoms in the pediatric population with a wide differential diagnosis. Imaging and endoscopic findings may suggest a malignancy and are not sufficient to render a precise diagnosis, which can only be made by pathologic examination.

Pathologic and molecular analysis in a family with rare mixed supravalvar aortic and pulmonic stenosis

Nonsyndromic supravalvar aortic stenosis (SVAS) is an obstructive vascular disorder often inherited in an autosomal dominant manner. With pulmonary artery involvement, stenotic lesions are nearly always peripheral or downstream of the pulmonic valve. In rare cases when the supravalvar pulmonic region is affected, the stenoses usually improve over time and rarely affect prognosis. We evaluated a unique family in which 10 of 14 individuals have nonsyndromic SVAS and 7 of the 10 affected family members with SVAS have the rare finding of supravalvar pulmonic stenosis (SVPS). In at least 2 of these individuals, the severity of SVPS was so significant that it led to death in early infancy. Pathologic examination of stenotic lesions in this kindred group revealed concentrically organized smooth muscle cells separated by dense elastic fibers. In contrast, the arterial pathology reported for other individuals with nonsyndromic SVAS demonstrates increased numbers of hypertrophied smooth muscle cells separated by thin, fragmented elastin fibers. Molecular analysis identified a novel ELN mutation within the donor splice site of exon 16, which may be responsible for the unique phenotype and distinct elastin histopathology found in this kindred.

Aortoiliac reconstruction in infants and toddlers: replacement with decellularized branched pulmonary artery allograft

BACKGROUND

Aortic reconstruction in infants and small children has been reported with Dacron or polytef prosthetic material, hypogastric artery autograft, and saphenous vein autograft. In children, synthetic grafts are limited by a concern for late infection and a lack of potential growth. Available autogenous vessels have a limited length and diameter. Conventional allografts have not been durable. When the entire infrarenal aorta and aortoiliac bifurcation must be replaced, none of the historic options are optimal.

METHODS

We report 2 cases of infrarenal aorta and aortoiliac bifurcation reconstruction using a new generation of cryopreserved allograft now decellularized for decreased immunogenicity. The branched pulmonary artery allograft is particularly attractive for reconstruction of the aortic bifurcation.

RESULTS

The postoperative course in both cases was uncomplicated. Follow-up with serial abdominal duplex ultrasound has shown no evidence of graft stenosis or calcification at 29 and 32 months, respectively.

CONCLUSIONS

The use of commercially available, decellularized, and antigen-reduced allograft offers a nonsynthetic option for replacement of the pediatric abdominal aorta. We chose this novel approach in hopes of reducing the lifetime risk for graft infection and maintaining the potential for graft ingrowth by the child.

Frozen Section Diagnosis in Pediatric Surgical Pathology: A Decade's Experience in a Children's Hospital

Context.—Intraoperative consultations, including frozen sections (FSs), are essential for patient care and are a key quality component in anatomic pathology. Little data exists about the use, frequency, and type of discrepancies and deferral rates of FS diagnoses in pediatric and adolescent surgical pathology.

Objective.—The purpose of this study was to analyze indications, discrepancies, and deferrals for all FSs performed at a children's hospital during a 10-year period.

Design.—All FSs for 1995–2004 were reviewed for indications, discrepancies, deferred diagnoses, and turnaround time. Discrepancies were categorized into major and minor subtypes according to potential impact on patient care.

Results.—A total of 35 611 surgical pathology cases were accessioned, with 2839 intraoperative consultations, which included 2783 FSs and 56 nonmicroscopic consultations. Most frequent indications included questions related to neoplasms (tumor detection, specimen adequacy, triage, classification, and margins) and suspected Hirschsprung disease. In these consultations, 115 discrepancies (4%) were identified, of which 7 (0.2%) were major, with potentially significant clinical impact, and 108 (3.9%) were minor. The major discrepancies included tumor, ganglion cell, or organism detection. The minor discrepancies involved sampling error, reclassification of benign or malignant neoplasms without clinical consequences, tumor typing or grading, and ganglion cell identification without clinical impact. Deferrals in 718 FSs (25% deferral rate) included tumor classification from generic to specific, identification of organisms, and evaluation of lymph node biopsies for lymphoma. Turnaround time exceeded 20 minutes in 403 cases (14%).

Conclusions.—The FS rate of 7.8% overall and 5% of surgical pathology cases is similar in children's and general hospitals. The major discrepancy (discordance) rate is lower, which may reflect the different indications for FS in children and adolescents. Evaluation of colonic biopsies for ganglion cells is a diagnostic pitfall. The deferral rate of 25% reflects the definition of a deferred diagnosis. Traditional definitions of deferred and discordant FS diagnoses should be refined to reflect the increasing use of adjunct techniques, especially in tumor classification. These findings emphasize that, in children and adolescents, most FSs are performed for tumor classification, triage, detection, and specimen adequacy, and for possible Hirschsprung disease. In children and adolescents, FSs are used infrequently to identify normal or unknown tissue, to analyze a lesion in a radiographically directed specimen, or to detect lymph node metastases. The differences in pediatric and adolescent FS indications and use underscore the importance of focused education in pediatric surgical pathology.

How the pediatric autopsy yields valuable information in a vertically integrated health care system

CONTEXT

Although autopsy rates have declined significantly in recent decades, studies continue to validate the autopsy as an important source of clinically relevant information, a teaching tool, and a quality assurance measure. A recent review of autopsy series showed a decline in the number of serious errors likely to have affected clinical outcome detected at autopsy during the past 46 years, with a current major error rate of 8.4% to 24.4%.

OBJECTIVE

Our hypothesis was that the pediatric autopsy would uncover a significant number of major unexpected findings at the high end of the spectrum predicted by a recent review. This study assesses the unexpected findings at a pediatric hospital whose autopsy service handles both in-house (tertiary care) and referral (mostly perinatal) cases for a vertically integrated health care system.

DESIGN

Data were analyzed from an autopsy effectiveness report completed for all autopsies performed in 2000. The data from this series include concordance of premortem and postmortem diagnoses, with the autopsy considered the criterion standard. The autopsy effectiveness report also provided logistic information, such as problems with consents, medical records, specimen identification, and prosection.

SETTING

Pediatric autopsies were performed by members of the Pediatric Pathology Division in a freestanding children's hospital in the Intermountain West of the United States with a large rural catchment area. This hospital is part of a large health maintenance organization serving the surrounding urban and rural areas.

PATIENTS

A sample of all in-house and referral autopsies for the year 2000 was examined.

MAIN OUTCOME MEASURE

The percentage of cases with a major or minor diagnostic discrepancy or unexpected pathologic finding using the autopsy as the criterion standard.

RESULTS

The overall autopsy rate was 40% (39 hospital autopsies and 15 forensic autopsies per 135 total deaths) and was 32% excluding forensic cases. Twenty-two additional referral autopsies from outside institutions were performed. Of 61 autopsies, 12 (20%) revealed a major diagnostic discrepancy or unexpected pathologic finding, 17 (28%) had a minor unexpected finding or additional diagnosis, 41 (67%) clarified the differential diagnosis, 46 (75%) confirmed or verified a major diagnosis, and 21 (34%) provided information regarding treatment effects. Additionally, 3 (5%) had problems with identification, and 12 (20%) had problems with consent, all of which were resolved prior to initiation of the autopsy.

CONCLUSIONS

These data confirm the value of the pediatric autopsy in a children's hospital and a vertically integrated health care system. It is an important medical and quality assurance procedure for assessing the accuracy of diagnoses, clarifying differential diagnoses, yielding unexpected findings, and providing feedback regarding therapeutic outcomes.

Treatment effects in pediatric soft tissue and bone tumors: practical considerations for the pathologist

Dramatic improvements in survival for children with cancer have led to increased numbers of posttreatment pathologic specimens, particularly in bone and soft tissue sarcomas. Current therapeutic protocols in North America require specific pathologic classification and stratify patients based on clinical, biologic, and pathologic features. For osteosarcoma, the pathologic response to therapy predicts prognosis and modifies the treatment regimen. Ongoing studies aim to assess the response to therapy and outcome in other types of soft tissue and bone tumors. The pathologic evaluation of pretreatment and posttreatment specimens is critical for therapeutic decisions and prognostic assessment. A standardized approach to posttherapy pathologic specimens, with attention to appropriate use of ancillary tests, and assessment of clinical and biologic significance of therapy-induced pathologic changes has significance for patient management and treatment protocols.

Cytogenetics of a pediatric unclassified sex cord-stromal tumor of the testis: a case report

Unclassified sex cord-stromal tumors account for a small proportion of pediatric testicular tumors and, while most are clinically benign, some have demonstrated malignant potential. Histological findings do not correlate well with clinical behavior and, while cytogenetics may aid in both diagnosis and predicting clinical behavior, these data on sex cord-stromal tumors are scarce. We describe an unclassified sex cord-stromal tumor occurring in the testis of a prepubertal male without evidence of metastasis that had a previously unreported 54,XY,+3,+7,+9,+12,+13,+18,+19,+20 karyotype.

Pediatric celiac disease: clinicopathologic and genetic aspects

Evaluation for celiac disease (CD), an autoimmune enteropathy triggered by grain proteins in wheat, barley, rye, and possibly oats, is a common indication for pediatric endoscopy and biopsy. Duodenal or jejunal biopsy remains key for the initial diagnosis of CD. Small intestinal pathology may be diffuse or focal in CD, and histologic findings are nonspecific and must be interpreted in conjunction with clinical and serologic findings. A standardized grading system for CD biopsies is recommended. This review article summarizes the epidemiology, clinical manifestations, genetics, pathogenesis, and serologic and histologic findings of CD. Clinical management of CD and general handling of small intestinal biopsies are also addressed.

Gastrointestinal polyposis in childhood: clinicopathologic and genetic features

Gastrointestinal polyps and certain extraintestinal lesions in children may herald a hereditary polyposis syndrome, with an increased risk of neoplasia and other health problems for both children and their relatives. The availability of molecular/genetic screening tests has increased early diagnosis of younger members of known polyposis families. This article reviews the gross and microscopic features of polyposis syndromes of childhood and summarizes the molecular/genetic advances in this field. Clinical management is also briefly discussed.

Bladder augmentation in dogs using the tissue capsule formed around a perivesical tissue expander

PURPOSE

Enterocystoplasty provides needed improvement in bladder storage parameters in many patients but it also generates significant morbidity. We evaluated the unusual potential alternative of using the capsule that forms around a standard silicone tissue expander placed perivesically to augment the bladder in dogs.

MATERIALS AND METHODS

Six mongrel dogs underwent baseline videourodynamics and assessment of serum electrolytes, followed by placement of a 250 to 500 cc perivesical silicone tissue expander. Four months after implantation the tissue expander was removed and the fibrous capsule around the expander was biopsied. The capsule was opened and anastomosed to the bladder to augment storage. Serum electrolytes were determined 2 and 4 weeks after augmentation. Videourodynamics were repeated after 3 to 5 months, that is at sacrifice. The harvested bladders underwent histological evaluation.

RESULTS

Five dogs underwent augmentation as described, while in an additional dog that underwent intraperitoneal placement of the tissue expander a fibrous capsule failed to form. Of the 5 augmented dogs 4 underwent repeat urodynamic and electrolyte evaluation with harvesting of the lower urinary tract, while 1 died of undetermined causes 3 weeks after augmentation. A distinct capsule formed in all dogs and augmentation was technically achievable. Anastomosis calcification in 3 dogs limited filling the augmenting capsule for cystography. Bladder capacity and compliance improved in all animals but it varied in degree. Histological examination of the capsule biopsies showed collagen rich connective tissue without epithelium or smooth muscle. After augmentation the capsular segment revealed urothelium in all cases with squamous metaplasia in 1. The subepithelial region had dense fibrosis and a thin band of osseous metaplasia occupied the lamina propria in all cases. Disorganized smooth muscle bundles were noted in all augmented bladders within the collagen of the capsule wall.

CONCLUSIONS

Bladder augmentation with the collagenous capsule formed over a perivesical tissue expander is technically feasible. There was evidence of epithelial and smooth muscle ingrowth from the native bladder with improved bladder capacity and compliance in all dogs. Osseous metaplasia of the luminal surface of the collagen based capsule that developed in all animals may have been responsible for anastomotic narrowing and limited filling on cystography.

Bladder augmentation in dogs using the tissue capsule formed around a perivesical tissue expander

PURPOSE

Enterocystoplasty provides needed improvement in bladder storage parameters in many patients but it also generates significant morbidity. We evaluated the unusual potential alternative of using the capsule that forms around a standard silicone tissue expander placed perivesically to augment the bladder in dogs.

MATERIALS AND METHODS

Six mongrel dogs underwent baseline videourodynamics and assessment of serum electrolytes, followed by placement of a 250 to 500 cc perivesical silicone tissue expander. Four months after implantation the tissue expander was removed and the fibrous capsule around the expander was biopsied. The capsule was opened and anastomosed to the bladder to augment storage. Serum electrolytes were determined 2 and 4 weeks after augmentation. Videourodynamics were repeated after 3 to 5 months, that is at sacrifice. The harvested bladders underwent histological evaluation.

RESULTS

Five dogs underwent augmentation as described, while in an additional dog that underwent intraperitoneal placement of the tissue expander a fibrous capsule failed to form. Of the 5 augmented dogs 4 underwent repeat urodynamic and electrolyte evaluation with harvesting of the lower urinary tract, while 1 died of undetermined causes 3 weeks after augmentation. A distinct capsule formed in all dogs and augmentation was technically achievable. Anastomosis calcification in 3 dogs limited filling the augmenting capsule for cystography. Bladder capacity and compliance improved in all animals but it varied in degree. Histological examination of the capsule biopsies showed collagen rich connective tissue without epithelium or smooth muscle. After augmentation the capsular segment revealed urothelium in all cases with squamous metaplasia in 1. The subepithelial region had dense fibrosis and a thin band of osseous metaplasia occupied the lamina propria in all cases. Disorganized smooth muscle bundles were noted in all augmented bladders within the collagen of the capsule wall.

CONCLUSIONS

Bladder augmentation with the collagenous capsule formed over a perivesical tissue expander is technically feasible. There was evidence of epithelial and smooth muscle ingrowth from the native bladder with improved bladder capacity and compliance in all dogs. Osseous metaplasia of the luminal surface of the collagen based capsule that developed in all animals may have been responsible for anastomotic narrowing and limited filling on cystography.

Cholesterol and development: the RSH ("Smith-Lemli-Opitz") syndrome and related conditions

The half-century of lipophobia in the United States may be abating with some return of sanity on the discussion of health and dietary fat [Taubes, 2001]. The youngest victims of this collective, decades long madness are those infants deprived for one reason or another of breast milk. They are unable to speak for themselves at a time of greatest need for cholesterol during growth, the most critical period of myelination of central and peripheral nervous system, formation of bone and bile, and of every steroid hormone. Some of the commercial formulas they are fed contain only 1 or 2 mg of cholesterol per 100 g edible portion contrasted with almost 14 mg in breast milk. One can only hope that the confidence in their endogenous ability to synthesize sufficient amounts of cholesterol is not misplaced. Pediatric pathology has learned that when this endogenous ability fails during embryogenesis on the basis of mutations in the postsqualene biosynthesis of cholesterol, a startling variety of developmental pathology may present itself ranging from lethal forms of "idiopathic" hydrops, microcephaly with cerebral dysgenesis and dysmyelinization, agenesis of corpus callosum, cerebellar vermis dysgenesis, cataracts, cleft palate, many different forms of congenital heart defect, pyloric stenosis and/or Hirschsprung dysganglionosis, adrenal (cortical) insufficiency, cholestatic liver disease, limb malformations, and genital ambiguity in genetic males. Population genetic considerations suggest a hypothetical birth prevalence of the RSH (so-called Smith-Lemli-Opitz) syndrome, the commonest of these Garrodian errors of cholesterol biosynthesis, of 1/2500; since only about 1/15,000 to 1/20,000 homozygotes are liveborn and biochemically confirmed, over 80% prenatal or perinatal mortality must occur and deserves the most discerning of services from birth attendants, perinatologists, neonatologists, and fetal/pediatric pathologists. An easy, reliable, economical biochemical test for the presence of 7-dehydrocholesterol is available and the commonest mutation, the IVS8-1G-->C mutation, is quickly and reliably tested for molecularly. Thus, the successful diagnosis, even after death, will contribute substantially to correct genetic counseling, carrier detection, prenatal diagnosis, and treatment in those known to be affected prenatally andplanned to be liveborn. Thus, developmental pathology plays an integral, vital role in preventive medicine.

Evidence by spectral karyotyping that 8q11.2 is nonrandomly involved in lipoblastoma

We report two cases of lipoblastoma with chromosome 8-related aberrations, ie, a 92,XXYY,t(7;8Xp22;q11.2)x2 [8]/46,XY[16] in Case 1 and a 46,XY,-8,-13,add(16) (q22),+mar, +r [cp13]/46,XY[7] in Case 2. Using spectral karyotyping and fluorescence in situ hybridization techniques, the karyotype of Case 2 was redesignated as 46,XY, r(8), del(13)(q12), der(16)ins(16;8)(q22; q24q11.2)[cp13]/46,XY[7]. This report delineates a new chromosome rearrangement, ie, der(16)ins(16;8)(q22; q24q11.2) in lipoblastoma, and also confirms the t(7; 8)(p22;q11.2), reported only once previously, as a recurrent translocation involved in such a tumor. These findings provide valuable information for clinical molecular cytogenetic diagnosis of lipoblastoma. Furthermore, this report highlights the value of cytogenetic and molecular cytogenetic analysis in differential diagnosis of childhood adipose tissue tumors and adds to the number of lipoblastomas reported with chromosomal abnormalities at 8q11.2.

Acute renal failure: unusual complication of Epstein-Barr virus-induced infectious mononucleosis

A 17-year-old boy with juvenile rheumatoid arthritis presented with jaundice, confusion, hemolytic anemia, thrombocytopenia, and acute renal failure secondary to titer-confirmed acute Epstein-Barr virus (EBV). Renal biopsy specimen revealed interstitial nephritis with an inflammatory infiltrate composed of cytotoxic/suppressor T cells, and interstitial mononuclear cell nuclei expressed EBV encoded RNA-1 (EBER-1) mRNA. Methylprednisolone treatment resulted in rapid improvement.

Therapy associated changes in childhood tumors

Contemporary treatment regimens for the common solid tumors of childhood have led to increased numbers of post-treatment pathologic specimens from survivors. Current therapeutic strategies for childhood cancers in North America require an accurate pathologic diagnosis and stratify patients based on combinations of clinical, biological, and pathologic features. In several tumor systems, the pathologic response to therapy also modifies the treatment regimen. Accurate pathologic interpretation of such specimens is critical in providing useful prognostic information for therapeutic decisions. Standardized handling of post-therapy pathologic specimens, appropriate use of molecular and genetic studies, consideration of the differential diagnoses, and assessment of the potential biologic significance of therapy-induced pathologic changes are, therefore, critical for patient management and determination of treatment protocols.

Inverted papilloma of the urinary bladder in children: case report and review of prognostic significance and biological potential behavior

Inverted papilloma of the urinary bladder is rare in the pediatric population. Despite several reports in the literature the prognostic significance and biological potential behavior of this lesion remain uncertain. The authors report a case of polypoid inverted papilloma of the urinary bladder in an 11-year-old boy and review its pathology. The pediatric population with this lesion is an ideal group to provide intense, long-term follow-up to define the biological behavior and prognosis significance of this lesion.

Bannayan-Riley-Ruvalcaba syndrome: spectrum of intestinal pathology including juvenile polyps

Bannayan-Riley-Ruvalcaba syndrome (BRRS) is a disorder that includes juvenile polyposis as part of its pathologic spectrum, and it recently has been shown to share phenotypic and genotypic features with Cowden's disease. In existing literature, descriptions of intestinal pathology in patients with BRRS are relatively sparse and occasionally erroneous. We describe the intestinal pathology in multiple specimens from three children with BRRS. Examination of gastrointestinal biopsies from these children revealed predominantly colonic and rectal polyps with the histology of juvenile polyps. Additionally, two cases with clusters of ectopic ganglion cells within the lamina propria, one in a colonic polyp and one in a duodenal biopsy, and an atypical polyp were observed. Bannayan-Riley-Ruvalcaba syndrome should be included in the list of differential diagnostic considerations when a child or young adult presents with a juvenile polyp, particularly if unusual histologic features such as atypical polyps or ectopic ganglion cells are encountered.

Inflammatory (pseudosarcomatous) myofibroblastic tumor of the urinary bladder causing acute abdominal pain

Inflammatory myofibroblastic tumor is a reactive proliferation of myofibroblasts that rarely involves the urinary bladder. The cause of inflammatory myofibroblastic tumor is unknown but may represent an initial reactive process to an infectious agent or trauma that transforms into neoplastic growth. Cases reported in children, however, often lack any preexisting bladder pathology. The authors present a case in a young child that presented as acute abdominal pain. In general, these tumors follow a benign clinical course after resection, although close monitoring is essential given the rarity of this bladder lesion.

Chemistry test ordering patterns after elimination of predefined multitest chemistry panels in a children's hospital

Predefined multitest chemistry panels (PMCPs) have constituted a large proportion of laboratory tests and patient charges, even in pediatric settings, despite the absence of documented clinical utility for PMCPs and the general availability of random access analyzers that do not require predefined test combinations. We eliminated PMCPs in our tertiary children's hospital but placed no other restrictions on ordering, and observed a 32.7% reduction in the number of automated chemistry tests ordered. All 23 tests in the previous PMCPs showed a decline in utilization, >50% for 8 of the tests and 20-50% for 13 others, and this change was sustained throughout an 8-month follow-up period. The total number of orders for one or more tests increased by 8.2%, but the variety of combinations that were ordered increased by 280%. The most substantial changes included a decrease in the number of orders for combinations of >15 tests, and increases in the number of orders for single tests and combinations of 2 to 5 tests. Orders for combinations identical to all of the former PMCPs declined, with the exception of the 4-test electrolyte panel. There was a marked decline in orders for a 7-test panel identical to the recently defined HCFA-AMA Basic Metabolic Panel, and orders for combinations identical to the HCFA-AMA Liver Function and Extended Metabolic panels were vanishingly rare and nonexistent, respectively. The calculated reduction in patient charges was much greater than actual cost savings, but the reduction in total tests and increase in the variety of test combinations suggest that significant savings can be realized if clinicians are encouraged to order only the tests or combinations they need without imposing procedural, financial, and regulatory burdens.

Craniopagus parasiticus: a case illustrating its relationship to craniopagus conjoined twinning

A case of craniopagus parasiticus is described in which the parasitic twin is more fully developed anatomically than in any of the previous reports. Somatic and placental vascular anastomoses between the twins and hypoplasia of the umbilical cord of the parasite were also observed. These findings support the hypothesis that craniopagus parasiticus results from compromise of the blood supply to one of a pair of craniopagus conjoined twins.

Eosinophilic infiltration of the enteric neural plexuses in Hirschsprung's disease

Inflammatory infiltrations of the enteric plexuses are uncommon and are usually lymphoplasmacytic. Within the past 15 years, nine pediatric cases in which a predominantly eosinophilic infiltrate of the gastrointestinal wall with a predilection for the myenteric (Auerbach's) and deep submucosal (Henle's) plexuses were seen at our institution. Two were neonates without gastrointestinal abnormalities who expired shortly after birth. Seven were patients with short-segment Hirsch-sprung's disease. There was a mild increase in mucosal eosinophils in the overlying mucosa and only one patient had peripheral eosinophilia. Follow-up data obtained 1 month to 7 1/2 years after biopsy revealed no development of inflammatory bowel disease, connective tissue disease, malignancy, allergic disorder, or intestinal dysmotility. The proximal location of the infiltrate suggests that it may represent a secondary finding rather than a primary cause of aganglionosis.

Prune-belly syndrome and other anomalies in a stillborn fetus with a ring X chromosome lacking XIST

Ring X chromosomes that lack the X inactivation center and fail to be inactivated have been implicated as a cause of mental retardation and multiple congenital anomalies. We report on a stillborn fetus with karyotype mos45,X/46,X,r(X) and early urethral obstruction or prune-belly sequence, single umbilical artery, limb deficiency, horseshoe kidney, cardiac hypertrophy, persistent left superior vena cava, and axial skeleton abnormalities. Fluorescent in situ hydridization (FISH) studies confirmed that the ring chromosome is X-derived and demonstrated that it lacks the XIST locus. The findings in this fetus are discussed with regard to the spectrum of phenotypes associated with monosomy X and small ring X chromosomes.