Biallelic EPCAM deletions induce tissue-specific DNA repair deficiency and cancer predisposition

We report a case of Mismatch Repair Deficiency (MMRD) caused by germline homozygous EPCAM deletion leading to tissue-specific loss of MSH2. Through the use of patient-derived cells and organoid technologies, we performed stepwise in vitro differentiation of colonic and brain organoids from reprogrammed EPCAMdel iPSC derived from patient fibroblasts. Differentiation of iPSC to epithelial-colonic organoids exhibited continuous increased EPCAM expression and hypermethylation of the MSH2 promoter. This was associated with loss of MSH2 expression, increased mutational burden, MMRD signatures and MS-indel accumulation, the hallmarks of MMRD. In contrast, maturation into brain organoids and examination of blood and fibroblasts failed to show similar processes, preserving MMR proficiency. The combined use of iPSC, organoid technologies and functional genomics analyses highlights the potential of cutting-edge cellular and molecular analysis techniques to define processes controlling tumorigenesis and uncovers a new paradigm of tissue-specific MMRD, which affects the clinical management of these patients.

Atypical Spitz tumor with SQSTM1::NTRK2 fusion: Report of a case with unique spindled cell features

A host of signature genetic alterations have been demonstrated in Spitz neoplasms, most notably fusions of kinase genes (including BRAF, ALK, ROS1, NTRK1, NTRK3, RET, MET, MAP3K8) or variants in HRAS. While there are multiple reports of rearrangements involving NTRK1 and NTRK3 in Spitz tumors, there are very few reports of NTRK2-rearranged Spitz nevi in the literature. This report presents an NTRK2-rearranged atypical Spitz tumor with spindled cell features. The patient was a 6-year-old female with a growing pigmented papule on the back. Histopathological evaluation revealed an asymmetric, biphasic, compound proliferation of melanocytes featuring an epithelioid cell population arranged as variably sized nests and single cells along the basal layer with extension down adnexa, as well as a population of spindled melanocytes with desmoplastic features and loss of Melan-A expression in the dermis. There was partial loss of p16 expression in the epidermal component and diffuse loss in the dermal component. Immunohistochemistry for PRAME, ALK, NTRK1, HRAS Q61R, p53, and BRAF V600E were negative. A SQSTM1::NTRK2 fusion was identified by RNA sequencing. No TERT promoter hotspot variants were detected. This case report expands the known histopathologic spectrum of genetic alterations in Spitz neoplasms.

Development of a Semi-Quantitative Food-Frequency Questionnaire for Korean Adults with Obesity

The increasing prevalence of obesity is a serious concern in Korea. However, there is currently no available food-frequency questionnaire (FFQ) for examining the dietary patterns of adults with obesity. This study aimed to develop a semi-quantitative FFQ tailored to Korean adults with obesity. The dish/food items for the FFQ were extracted from the 24 h recall data of 8450 Korean adults (aged 19-64 years) with obesity who participated in the 2013-2019 Korea National Health and Nutrition Examination Survey. Among the 1709 dishes consumed, 475 were selected based on their high contribution to the intake or substantial between-individual variation in 11 nutrients: energy, carbohydrates, dietary fiber, sugar, fat, saturated fat, protein, sodium, vitamin A, vitamin E, and flavonoids. These dishes were subsequently categorized into 129 items based on their recipes and primary ingredients. The final 129 items included rice; noodles and dumplings; breads, rice cakes, and cereals; soups and stews; eggs, pulses, meat, and fish; vegetables and kimchi; fruit; snacks; beverages; milk/dairy products; alcohol; and water. The response options for intake frequency comprised nine options, and the intake amount response included three options (50%, 100%, and 150-200% of the standard intake). After validation, this FFQ is expected to be used in epidemiological studies to investigate the dietary patterns of Korean adults with obesity.

A molecular staging model for accurately dating the endometrial biopsy

Natural variability in menstrual cycle length, coupled with rapid changes in endometrial gene expression, makes it difficult to accurately define and compare different stages of the endometrial cycle. Here we develop and validate a method for precisely determining endometrial cycle stage based on global gene expression. Our 'molecular staging model' reveals significant and remarkably synchronised daily changes in expression for over 3400 endometrial genes throughout the cycle, with the most dramatic changes occurring during the secretory phase. Our study significantly extends existing data on the endometrial transcriptome, and for the first time enables identification of differentially expressed endometrial genes with increasing age and different ethnicities. It also allows reinterpretation of all endometrial RNA-seq and array data that has been published to date. Our molecular staging model will significantly advance understanding of endometrial-related disorders that affect nearly all women at some stage of their lives, such as heavy menstrual bleeding, endometriosis, adenomyosis, and recurrent implantation failure.

Eosinophilic Annular Erythema Responding to Doxycycline

Eosinophilic annular erythema (EAE) is a rare skin disease characterized by relapsing and remitting pruritic, annular erythematous plaques and tissue eosinophilia. A 39-year-old male presented with a mildly pruritic, relapsing, and remitting urticarial rash. A biopsy revealed superficial and deep perivascular dermatitis with numerous eosinophils and some neutrophils, with an absence of flame figures. Based on clinical and histopathologic findings, the patient was given a diagnosis of eosinophilic annular erythema. Treatment was initiated with doxycycline 100 mg twice daily. The patient reported substantial improvement at three months and sustained clearance at one year, remaining on doxycycline well tolerated throughout. To our knowledge, no cases of EAE improving with doxycycline have been reported in the literature and, thus, our findings highlight a potential new therapy to consider in a patient with EAE.

Observational cohort study to validate SEARCH, a novel hierarchical algorithm to define long-term outcomes after pulmonary embolism

BACKGROUND

Chronic dyspnoea and exercise impairment are common after acute pulmonary embolism (PE) but are not defined and quantified sufficiently to serve as outcomes in clinical trials. The planned project will clinically validate a novel method to determine discrete, clinically meaningful diagnoses after acute PE. The method uses an algorithm entitled SEARCH, for symptom screen, exercise testing, arterial perfusion, resting echocardiography, confirmatory imaging and haemodynamic measurements. SEARCH is a stepwise algorithm that sorts patients by a hierarchical series of dichotomous tests into discreet categories of long-term outcomes after PE: asymptomatic, post-PE deconditioning, symptoms from other causes, chronic thromboembolism with ventilatory inefficiency, chronic thromboembolism with small stroke volume augmentation, chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension.

METHODS

The project will test the inter-rater reliability of the SEARCH algorithm by determining whether it will yield concordant post-PE diagnoses when six independent reviewers review the same diagnostic data on 150 patients evaluated at two time points after PE. The project will also determine whether the post-PE diagnoses are stable, according to the SEARCH algorithm, between the first evaluation and the subsequent one 6 months later.

IMPLICATIONS

Validation of the SEARCH algorithm would offer clinicians a straightforward method to diagnose post-PE conditions that are rarely distinguished clinically. Their categorisation and definition will allow post-PE conditions to be used as endpoints in clinical trials of acute PE treatment.

TRIAL REGISTRATION NUMBER

NCT05568927.

Non-sebaceous lymphadenoma arising as a painless subcutaneous nodule on the eyebrow

Salivary gland tumors can rarely present on skin excision specimens and can pose a diagnostic challenge to dermatopathologists. We present an exceptional case of a salivary gland type non-sebaceous lymphadenoma presenting as a painless subcutaneous nodule on the right medial eyebrow of a 16-year-old male, mimicking a primary cutaneous adnexal neoplasm. Histologic evaluation revealed a well-circumscribed to partially encapsulated nodule with a marked lymphoid infiltrate including reactive germinal centers. Within the lymphoid component was a central epithelial cystic neoplasm with tubuloglandular and basaloid differentiation. There was no myoepithelial component to suggest a chondroid syringoma. No sebaceous differentiation was present. The overall histological and immunohistochemical findings were consistent with a non-sebaceous lymphadenoma. Dermatopathologists should consider salivary-gland type lymphadenoma as a differential diagnosis when encountering a subcutaneous lesion with lymphoid, cystic, glandular, and basaloid components. This article is protected by copyright. All rights reserved.

Dysregulation of immune cell and cytokine signaling correlates with clinical outcomes in myelodysplastic syndrome (MDS)

OBJECTIVES

Myelodysplastic syndromes (MDS) are characterized by ineffective hematopoiesis. Although hypomethylating agents (HMA) have improved survival in higher-risk MDS, most patients eventually succumb to progressive disease. Utilizing samples collected prospectively from three MDS clinical trials, we analyzed genetic and immunological biomarkers and correlated them with clinical outcomes.

METHODS

154 samples were analyzed from 133 de novo MDS patients for T-cell and myeloid cell immunophenotyping and gene expression analysis. Treatments were with HMA or immunomodulatory drug (IMiD) alone or in combination.

RESULTS

We observed differences in immune cell subsets between lower and higher risk IPSS groups with NKT cells, MDSCs, intermediate-proinflammatory and non-classical monocytes being higher in the latter group while naïve CD4+ T-cells were reduced. Intermediate-proinflammatory monocytes were increased in non-responders and those failing to achieve at least a hematological improvement. Pro-inflammatory NKT cells were increased at diagnosis for patients failing to derive clinical benefit after 12 months of treatment. Gene expression analysis of paired bone marrow (BM) colony-forming units (CFUs) from diagnosis and 4 cycles post-treatment confirmed that genes involved in cytokine signaling were downregulated in C4 normal colonies.

CONCLUSIONS

These findings support the central roles of dysregulation in innate immunity and inflammatory signaling in the pathogenesis of MDS which correlated with clinical outcomes post-treatment.

Generalized Multinucleate Cell Angiohistiocytoma: Histopathological and Immunohistochemical Analyses of 10 Lesions

ABSTRACT

Multinucleate cell angiohistiocytoma (MCAH) is an uncommon fibrohistiocytic disorder that usually presents as a localized solitary papule or multiple grouped papules. Generalized presentation is very rare with less than 20 cases reported in the literature. In this article, we present histopathological and immunohistochemical studies of 10 lesions from a patient with generalized MCAH. In all lesions, the histopathological changes were confined to a discrete zone of the superficial dermis that consisted of (1) an increase in the number of capillary-sized vessels with thickened walls, (2) presence of oval to dendritic spindle cells and stellate hyperchromatic multinucleated cells, (3) fibrosis marked by compact collagen, (4) hypertrophy and hyperplasia of small nerve fibers, and (5) a moderately dense lymphocytic infiltrate. The entire population of the cellular component including the multinucleated cells stained for CD10, whereas a subpopulation of the mononuclear spindle cells stained for factor XIIIa and CD68. CD34 highlighted only the blood vessels. The results confirm that the multinucleated cells lack expression of CD68 and factor XIIIa and that CD10 may be used to highlight the entire cellular component. The rarely reported hypertrophy and hyperplasia of nerve fibers in MCAH may be a common finding as it was observed in all 10 lesions.

Expression of p40 in Primary Cutaneous Mucinous Carcinoma Versus Primary Mucinous Carcinomas of the Breast and Colon

BACKGROUND

The transcription factor p63 is a homolog of p53, expressed in basal layers of epithelia and myoepithelial cells. Some studies have suggested that p63 may provide utility in differentiating primary versus metastatic mucinous carcinoma of the skin, given its preferential expression in primary adnexal neoplasms. There have been few studies investigating the expression patterns of p40, an isoform of p63, in primary cutaneous mucinous carcinomas.

METHODS

An immunohistochemical panel including p40, CK7, CK20, estrogen receptor, and progesterone receptor was applied to primary mucinous carcinomas of the skin, breast, and colon.

RESULTS

Only a small subset (25%) of primary cutaneous mucinous carcinomas displayed focal positive staining with p40, similar to what has been reported in the literature for p63. All primary mucinous carcinomas of skin and breast labeled positively with CK7, estrogen receptor, and progesterone receptor. Primary colon mucinous carcinomas were only positive for CK20.

CONCLUSIONS

Based on these results, p40 seems to be an insufficient marker for distinguishing primary versus metastatic mucinous carcinoma due to its low rate of positivity in primary cutaneous mucinous carcinomas.

Society for Cardiovascular Magnetic Resonance 2020 Case of the Week series

The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). Case of the week is a case series hosted on the SCMR website ( https://www.scmr.org ) that demonstrates the utility and importance of CMR in the clinical diagnosis and management of cardiovascular disease. Each case consists of the clinical presentation and a discussion of the condition and the role of CMR in diagnosis and guiding clinical management. The cases are all instructive and helpful in the approach to patient management. We present a digital archive of the 2020 Case of the Week series of 11 cases as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar search engine.

Solvent-Assisted Hot Melt Extrusion of a Thermally Labile, High Melting Point Compound

Molecular dispersions are a highly effective method of increasing bioavailability for a poorly soluble active pharmaceutical ingredient (API) and can be prepared on a large scale by hot melt extrusion (HME). Processing thermally labile active pharmaceutical ingredients (APIs) via HME is generally more difficult, with operating temperatures limited to below that of the API melting point. API melting is considered essential to facilitate the formation of a fully homogeneous amorphous system. Processing below the melting point renders the system much more susceptible to residual crystalline content; hence, HME is not suitable for APIs which degrade upon melting. In the following work, meloxicam (MEL) was used as a model API, possessing properties of high melting temperature and thermal lability. In this proof of concept work, a modified HME method, termed solvent-assisted HME, was used to overcome this issue and prepare an amorphous solid dispersion using HME, wherein a solvent was incorporated in the formulation blend during extrusion and removed post-processing. Formulations containing 10%wt meloxicam (MEL) and 90%wt polyvinylpyrrolidone vinyl acetate (PVPVA) copolymer were extruded using a twin-screw extruder at temperatures below the melting point of MEL. Dimethylformamide (DMF) solvent was added directly into the extruder barrel through a liquid addition port, resulting in extrudate products having a higher conversion of API to the amorphous form. The incorporation of solvent allowed a significant reduction in processing temperatures due to its increased mobility, while also driving the conversion of the API to its amorphous form. The solvent was successfully reduced through a secondary drying step using a vacuum oven. This advancement has demonstrated the potential for thermally labile APIs to be processed via HME expanding the applications of this technology.

Safety and Efficacy of Stent-Assisted Coiling of Unruptured Intracranial Aneurysms Using Low-Profile Stents in Small Parent Arteries

BACKGROUND AND PURPOSE

Stent-assisted coiling of intracranial aneurysms arising from small vessels (≤ 2.0 mm) is a common procedure. However, data regarding its treatment outcomes are scarce. This study evaluated the clinical and radiologic outcomes of stent-assisted coiling using low-profile stents for aneurysms of small parent arteries.

MATERIALS AND METHODS

From November 2015 to October 2020, sixty-four patients with 66 aneurysms arising from parent arteries of ≤2.0 mm were treated with stent-assisted coiling using a Low-Profile Visualized Intraluminal Support Junior (LVIS Jr) or the Neuroform Atlas stent in a single institution. The clinical and radiologic data were retrospectively reviewed, and the risk factors for procedure-related complications were evaluated.

RESULTS

The LVIS Jr and Neuroform Atlas stents were used in 22 (33.3%) and 44 (66.7%) cases, respectively. Technical success was achieved in 66 cases (100%). Immediate postprocedural aneurysm occlusion grades assessed by the Raymond-Roy occlusion classification were I (57.6%), II (19.7%), and III (22.7%), respectively. Procedure-related complications occurred in 10 cases (15.2%), with 8 thromboembolic complications (12.1%) and 2 hemorrhagic complications (3.0%). Procedure-related morbidity was 4.5% without mortality. On multivariate analysis, current smoking (odds ratio = 7.1, P = .021) had a statistically significant effect on procedure-related complications.

CONCLUSIONS

Stent-assisted coiling of intracranial aneurysms with low-profile stents in small vessels (≤ 2.0 mm) had a 100% success rate and a 15.2% overall complication rate with 4.5% morbidity. Current smoking was a significant risk factor associated with procedure-related complications.

P–134 Zygote morphokinetic parameters (ZMP) differs between fertilized and non-fertilized (in vitro maturation) oocytes

Study question

Is there any difference on the ZMP between the fertilized and the non-fertilized oocytes in an IVM cohort?

Summary answer

The zona pellucida (zp_g) , cytoplasm greyscale（cm_g),the cytoplasm size (cm_size), radius (cm_r) and deviation (cm_d) showed different patterns from the two groups.

What is known already

We developed a convolutional neural network (CNN) based algorithm that provides instant and bias-free analytical outcomes of oocyte morphological segmentation. The mature but not-fertilized oocytes tend to be static while the fertilized oocytes are more dynamic for preparing its following biological events.

Study design, size, duration

This was a case-control study on oocytes including 631 normal fertilized oocytes and 100 IVM oocytes from 01/08/2017 to 31/12/2019 conducted in the Prince of Wales Hospital, The Chinese University of Hong Kong.

Participants/materials, setting, methods

We used the convolutional neural network (CNN) algorithm to segment the ZMPs of the cytoplasm and zona pellucida of the oocytes. The ZMPs include cm_g, cm_size, cm_r, cm_d, zp_g, thickness of zona pellucida and the area of perivitelline space. For the ZMPs that did not change with time, we used t-test to test the significance and for the parameters changed with time we used dynamic warp timing and similarity test to find the difference.

Main results and the role of chance

The IVM group had a higher intensity of zp_g of 142.03 (128.52–158.70) compared with the fertilized group of 137.04 (121.69–154.37). The cm_g of IVM group was higher than fertilized group [122.55 (114.87–137.62) vs 119.37(108.88–132.87)]. The cm_size, cm_r and cm_d as parameters changed with time and showed a different pattern in two groups. The IVM group decreased the cm_size faster than the fertilized group but the fertilized group had a more dynamic change in the shape of cytoplasm (cm_d) during the development. The cm_r changed with the same pattern of cm_size provided evidence supporting the finding above.

Limitations, reasons for caution

The ZMPs in the IVM group was captured for 21 hours from the first polar body extrusion. Though the duration was similar to the one from fertilized to the first cleavage. The morphology change during that period may not represent the holistic one of IVM oocytes.

Wider implications of the findings: The IVM oocytes have different morphokinetic performance from fertilized oocytes. We used a novel method based on CNN to confirm the differences between the two groups showing that our algorithm was able to describe the morphokinetic changes in a quantitative way and corresponded with embryologist’s experience.

Trial registration number

The Hong Kong Obstetrical & Gynaecological Trust Fund

Evolution of a melanoma in situ to a sarcomatoid dedifferentiated melanoma

Sarcomatoid dedifferentiated melanoma (SDDM) is a recently recognized subtype of melanoma that stains diffusely for CD10 and lacks the expression of the usual melanocytic markers including S100, SOX10, MITF, and Melan A. Advances in next-generation DNA sequencing technology have facilitated the increased recognition of this rare, aggressive spindle cell melanoma. Herein, a case of relatively early lesion of SDDM arising in association with melanoma in situ is highlighted. A 72-year-old man with a history of previously treated melanoma in situ on the face five years prior presented with a new rapidly growing lesion within the scar of the treated site. A shave biopsy of the lesion revealed a centrally located 1.8-mm deep, poorly differentiated spindle cell neoplasm in association with an adjacent recurrent melanoma in situ. The spindle cell component stained diffusely for CD10, but failed to stain for S100, SOX10, and Melan-A while the melanoma in situ expressed all three melanocytic markers. Next-generation DNA sequencing assay revealed mutations in NF1, CDKN2A, TP53, and TSC1. A diagnosis of stage 2B SDDM arising in association with melanoma in situ was established based on the clinical context and genomic assay results.

Incidence and predictors of postoperative ischaemic stroke after coronary artery bypass grafting in the United States

Background

Postoperative acute ischemic stroke (AIS) is a catastrophic complication of coronary artery bypass grafting (CABG). There is limited data on the incidence and outcomes of AIS complicating CABG in the contemporary era, and whether these have changed over the years.

Purpose

To study the incidence and outcomes of postoperative AIS in a nationally representative cohort of CABG procedures over a 12-year period and examine predictors of AIS in patients undergoing CABG.

Methods

The National Inpatient Sample was used to identify all adult patients (>18 years old) who underwent CABG in the United States between January 2004 and September 2015. Multivariable logistic regression was performed to examine the associations between postoperative AIS and in-hospital mortality and identify predictors of AIS after CABG, expressed as odds ratios (OR) with corresponding 95% confidence intervals (CI).

Results

A total of 2,569,597 CABG operations were analysed. The incidence of postoperative AIS was 1.8% (n=47,279) in the overall cohort increasing from 1.2% in 2004 to 2.3% in 2015 (p<0.001). Significantly higher rates of AIS were observed amongst patients with atrial fibrillation (AF) and those undergoing non-elective or concomitant valve operations over the study period (see Figure). Patient risk profiles increased over time in both AIS and no-AIS cohorts, with higher Charlson comorbidity scores observed amongst AIS patients. AIS was independently associated with increased odds of in-hospital mortality (OR 3.03, 95% CI 2.93, 3.13) and prolonged hospital stay (∼6 more days) and a higher hospitalisation cost (∼$80,000 more) (p<0.001 for all). Several factors were predictors of AIS including age>60 years (61–70 years: OR 1.33, 95% CI 1.29, 1.37; 71–80 years: OR 1.49, 95% CI 1.44, 1.54; >80 years: OR 1.42, 95% CI 1.37, 1.48), female sex (OR 1.33, 95% CI 1.31, 1.36) and AF (OR 1.14 95% CI 1.12, 1.16) (p<0.001 for all). In contrast, on-pump CABG was not an independent predictor of stroke (OR 1.01, 95% CI 0.94, 1.09) (p=0.784).

Conclusion

In this nationally representative study, we have shown that the rates of postoperative stroke following CABG have increased over time in line with complexity of patient risk profiles. The present findings emphasise the need for further work on strategies to reduce the risk of postoperative stroke after CABG.

Trends of postoperative AIS (2004-2015)

Funding Acknowledgement

Type of funding source: None

Current locoregional therapies and treatment strategies in hepatocellular carcinoma

Locoregional therapies (lrts) play an important role in the treatment of hepatocellular carcinoma (hcc), with the aim of increasing overall survival while preserving liver function. Various forms of lrt are available, and choosing the best one depends on technical aspects, liver morphology, tumour biology, and the patient's symptoms. The purpose of the present review article is to provide an overview of the current evidence relating to the use of percutaneous ablation, transarterial chemoembolization, and transarterial radioembolization for the curative or palliative treatment of hcc. Special situations are also reviewed, including the combined use of systemic therapy and lrt, indications and techniques for bridging to transplant and downstaging, and the use of lrt to treat patients with hcc and macrovascular invasion.

Clinical and histopathological features of pagetoid Spitz nevi of the thigh

BACKGROUND

Pagetoid Spitz nevus is a rare subtype of Spitz nevus usually found on the lower extremities, particularly on the thigh of women. As a rare and under-recognized entity that can be misdiagnosed as melanoma, further characterization of clinical and histopathological features is needed to improve its recognition.

METHODS

A retrospective analysis of all melanocytic neoplasms from the thigh diagnosed over a 3-year period.

RESULTS

Fifty-five (15.4%) of the 357 melanocytic neoplasms on the thigh were Spitz nevi, the majority of them occurring in women (87.3%). Of the 55 Spitz nevi, 33 (60.0%) were pagetoid Spitz nevi, 14 (25.5%) were Reed nevi, and eight (14.5%) were conventional Spitz nevi. The mean age of patients with pagetoid Spitz nevi was 47.2, the majority being women (84.9%). Pagetoid Spitz nevi were small, with a mean histopathologic diameter of 4 mm, and often junctional (63.6%). Compared to Clark nevi of the thigh, pagetoid Spitz nevi comprised significantly more solitary melanocytes with a greater degree of scatter.

CONCLUSIONS

These results suggest that Spitz nevi and, in particular, pagetoid Spitz nevi constitute a significant percentage of nevi on the thigh. Previously reported benign clinical and histopathological features of pagetoid Spitz nevi are confirmed in this study.